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MANUAL 

OF 


PSYCHIATEY. 


BY 

J.  ROGUES  DE  FURSAC,  M.D., 

Formerly  Chief  of  Clinic  at  the  Medical  Faculty  of  Paris. 


AUTHORIZED  TRANSLATION  FROM  THE  FRENCH 

BY 

A.  J.  ROSANOFF,  M.D., 

Junior  Assistant  Physician,  L.  I.  State  Hospital,  Kings  Park,  N.  Y. 


EDITED    BY 

JOSEPH   COLLINS,  M.D., 

Professor  of  Diseases  of  the  Mind  and  Nervous  System  in  the  New   York 

Post-Craduate  Medical  School ;  Physician  to  the  New   York  City 

Hospital;  Neurologist  to  the  Montefiore  Home  for  Chronic 

Invalids  ;  Consulting  Neurologist  to  the  Hospital 

for  Ruptured  and   Crippled,  the  Long 

Island  State  Hospital,  and  to 

the  Manhattan  State 

Hospital,  West. 


FIRST  EDITION. 
FIRST   THOUSAND. 


NEW  YORK : 

JOHN  WILEY   &   SONS. 

London:  CHAPMAN  &  HALL,  Limited. 

1905. 


R£>3 


Copyright,  1905, 

BY 

A.  J.  RGSANOFF. 


ROBERT   DRUMMOND,    PRINTER,   NEW   YORK. 


e 


TRANSLATOR'S   PREFACE. 


The  new  classification  of  mental  diseases  introduced 
by  Kraepelin  has  met  with  much  opposition  from 
the  medical  profession  in  general,  although  a  great 
many  alienists  have  adopted  it.  Since  this  classification 
is  based  upon  no  firmer  foundation  than  the  empirical 
one  of  clinical  observation,  it  cannot  be  doubted  that 
from  a  strictly  pathological  standpoint  some  of  the 
groups  are  quite  heterogeneous,  and  that  ultimately 
further  subdivisions,  changes  in  the  grouping,  and 
additions  will  be  necessary.  But  to  the  practical 
alienist  the  advantage  of  Kraepelin's  classification  over 
the  older  ones  is  very  considerable.  By  a  careful 
examination  of  the  history  and  of  the  physical  and 
mental  status  the  alienist  is  now  able  in  the  majority 
of  instances  to  assign  his  case  to  one  or  the  other  of  the 
great  groups  and  thus  to  determine  the  prognosis  with 
a  greater  degree  of  certainty  and  accuracy  than  was 
possible  formerly.  This  constitutes  the  chief  advance 
of  the  Kraepelin  school;  and  it  is  the  result  not  of  the 
changes  in  the  nomenclature,  but  of  an  essential  depart- 
ure in  the  methods  of  taking  the  mental  status  and  in 
the  interpretation  of  the  manifestations  of  the  diseased 
mind. 

Diagnostic  difficulties,  of  course,  arise  as  they  do  in 

iii 


iv  TRANSLATOR'S  PREFACE. 

all  clinical  work;  but  a  really  serious  drawback  lies  in 
the  fact  that  a  considerable  proportion  of  any  series  of 
consecutive  cases  is  found  to  be  unsuitable  for  inclusion 
in  any  of  the  groups;  whether  these  cases  are  formes 
jrustes  of  the  different  morbid  entities  or  whether  they 
are  really  conditions  which  are  not  covered  by  this 
classification  cannot  at  present  be  determined. 

A  word  to  the  beginner  in  psychiatry.  The  nomen- 
clature and  methods  of  the  insanity  clinic  differ  so 
greatly  from  those  of  general  medicine  that  the  average 
student  will  find  the  chapter  on  special  psychiatry 
almost  unintelligible  without  a  careful  preliminary 
study  of  those  on  general  psychiatry.  This  is  the 
case  with  this  more  than  with  most  other  similar  works, 
since  for  the  sake  of  brevity  no  detailed  descriptions  of 
the  individual  psychoses  are  given  in  the  second  part; 
there  is  in  most  cases  a  mere  mention  of  the  symptoms, 
for  the  recognition  and  interpretation  of  which  the 
student  is  referred  to  the  first  part. 

The  translator  has  tried  to  follow  closely  the  text 
of  the  French  original.  Several  slight  changes  have, 
however,  been  found  necessary. 

The  French  insanity  law  has  been  omitted.  The  spec- 
imens of  insane  utterances  showing  incoherence  and 
flight  of  ideas  have  been  obtained  from  the  clinical 
records  of  cases  at  the  Long  Island  State  Hospital  at 
Kings  Park,  N.  Y.,  as  it  was  found  impossible  to  make 
a  satisfactory  translation  of  the  French  specimens. 

The  translator's  notes  throughout  the  book  are  en- 
closed in  brackets. 

A.    J.    ROSANOFF. 

Kings  Park,  N.  Y.,  January  1905. 


TABLE   OF   CONTENTS. 


PAGE 

Translator's  Preface iii 

Introduction ix 

FIRST   PART:    GENERAL  PSYCHIATRY. 

CHAPTER 

I. — Etiology 1 

Multiplicity  of  causes  in  psychiatry. — General  and 
individual  predisposing  causes. — Pathogenesis  of  degen- 
eration.— Congenital  predisposition. — Morbid  heredity. 
— Acquired  predisposition. — Physical  and  moral  deter- 
mining causes. 

II. — Symptomatology. — Disorders   of   Perception 29 

Insufficiency  of  perception. — Illusions. — Hallucina- 
tions: properties  common  to  all  hallucinations;  the 
different  varieties  of  hallucinations;  theories  of  hal- 
lucinations. 

III. — Symptomatology  (continued).  —  Consciousness.  — 
Memory. —  Associations  of  Ideas. —  Judg- 
ment 55 

Unconsciousness.  —  Clouding  of  consciousness. — 
Disorientation. —  States  of  obscuration. —  Hypercon- 
sciousness. — Different  forms  of  amnesia. — Distortions 
of  past  impressions. — Enfeeblement  of  the  attention. 
— Flight  of  ideas. — Incoherence. — Imperative  ideas. — 
Fixed  ideas.  —  Autochthonous  ideas,  —  Disorders  of 
judgment. — Delusions. 

v 


vi  TABLE   OF  CONTENTS. 


IV. — Symptomatology    (continued) .  —  Affectivity.  —  Re- 
actions.— Personality 79 

Morbid  indifference. — Exaltation  of  the  affectivity. 
— Morbid  depression,  joy,  and  anger. — Aboulia. — Auto- 
matic reactions.  —  Suggestibility.  —  Impulsiveness.  — 
Stereotypy. — Negativism. — Disorders  of  ccenesthesia. 
— Alterations  of  personality. 

V. — The  Practice  of  Psychiatry. — Examination  of 
Patients. — General  Therapeutics  of  the 
Psychoses • 99 

Anamnesis. — Direct  examination. — Simulation  and 
dissimulation. — Insane-asjdums. — Commitment,  phy- 
sician's certificate. — Medico-legal  questions:  respon- 
sibility.— Treatment  of  excitement,  of  suicidal  ideas, 
and  of  refusal  of  food. 


SECOND  PART:  SPECIAL  PSYCHIATRY. 

Classification 121 

I. — Deliria  of  Infectious  Origin:    Febrile  Delirium. — 

Infectious  Delirium  Proper. — Hydrophobia.  ...    124 

II. — Psychoses  of  Exhaustion:  Primary  Mental  Con- 
fusion; Acute  Delirium 129 

III. — Acute     Alcoholic     Intoxication     (Pathological 

Drunkenness) 138 

IV. — Chronic  Alcoholism:  Permanent  Symptoms. — Eti- 
ology.— Epidosic  Accidents:  Delirium  Tremens; 
Alcoholic  Systematized  Delirium 142 

V. — Chronic    Intoxication   by   the   Alkaloids:     Mor- 

phinomania. — Cocainomania 163 

VI. — Psychoses  of  Autointoxication,  Acute  and  Sub- 
acute: Unemic  Delirium.  —  The  Polyneuritic 
Psychosis 173 

VII. — Thyrogenic  Psychoses:  Myxcedema. — Cretinism...    180 

VIII. — Dementia  Precox. — Chronic  Delirium 180 


TABLE   OF  CONTENTS.  vil 

CHAPTER  PAGE 

IX. — General  Paresis 211 

X. — Mental    Disorders    Due    to    Organic    Cerebral 

Affections 250 

XI. — Psychoses  of  Involution:  Affective  Melancholia. — 

Senile  Dementia 256 

XII. — Manic  Depressive  Insanity:  Manic  Type.  —  De- 
pressed Type.  —  Mixed  Types. — Attacks  of 
Double  Form. — Periodic  Insanity. — Alternating 
Insanity. — Circular  Insanity 268 

XIII. — Reasoning  Insanity  (Kraepelin's  Paranoia) 292 

XIV. — Constitutional  Psychopaths:  Mental  Instability. — 

Sexual  Perversion  and  Inversion. — Obsessions.    298 

XV. — The  Mental  Disorders  of  Epilepsy 311 

XVI. — The  Mental  Disorders  of  Hysteria 321 

XVII. — Arrests    of    Mental    Development:     Idiocy    and 

Imbecility. — Moral  Insanity 327 


INTEODUCTION. 


Psychiatry  is  that  branch  of  neurology  which  treats 
of  mental  disorders  and  of  the  organic  changes  asso- 
ciated with  them. 

Mental  disorders  arrange  themselves  in  two  funda- 
mental categories,  characterized  respectively  by  insuffi- 
ciency and  'perversion  of  the  intellectual  or  moral  facul- 
ties. 

Insufficiency  may  be  either  congenital  or  acquired. 
In  the  first  case  it  constitutes  an  arrest  of  development; 
in  the  second,  psychic  paralysis.  When  the  psychic 
paralysis  is  temporary,  causing  a  suspension,  but  not  a 
destruction,  of  mental  activity,  the  name  psychic  inhibi- 
tion is  applied  to  it;  on  the  other  hand,  when  it  is  per- 
manently established,  it  constitutes  intellectual  enfeeble- 
ment  or  dementia. 

Perversion  of  the  intellectual  and  moral  faculties 
may  also  be  congenital  or  acquired.  Generally  it  results 
from  an  exaggeration  of  the  mental  automatism,  and 
is  designated  by  different  terms,  depending  upon  the 
particular  function  affected:  hallucinations,  delusions, 
morbid  impulses,  etc. 

is 


x  INTRODUCTION. 

Mental  diseases  or  psychoses  are  affections  in  which 
the  mental  symptoms  constitute  a  prominent  feature. 
They  differ  from  such  mental  infirmities  as  idiocy, 
moral  insanity,  and  many  states  of  dementia,  in  that 
they  are  expressions  of  active  pathological  processes 
and  not  of  permanent  and  fixed  alterations  of  the 
mind. 

Psychic  infirmity,  when  not  congenital,  occurs  as  the 
ultimate  outcome  of  some  mental  disease.  The  rela- 
tion between  the  two  conditions  is  analogous  to  that 
which  exists  between  ankylosis  of  a  joint  and  the  ar- 
thritis which  produced  it;  the  latter  is  a  disease,  the 
former  an  infirmity. 

When  mental  symptoms  appear  to  exist  alone,  the 
mental  disease  is  said  to  be  idiopathic,  and  is  called 
a  vesania;  when  they  are  associated  with  alterations  of 
the  organic  functions  the  disease  is  said  to  be  symp- 
tomatic or  secondary.  This  distinction  is  superfluous, 
and  the  subdivision  resulting  from  it  is  artificial.  In 
fact,  the  more  the  efforts  of  alienists  are  directed  to  the 
study  of  the  coexisting  somatic  disturbances,  the  more 
restricted  does  the  number  of  the  vesanias  become.  The 
psychopathic  processes  which  Kraepelin  has  designated 
by  the  term  dementia  prgecox  have  for  a  long  time  been 
classified  under  various  headings  among  the  vesanias. 
Now,  the  number  of  physical  signs  observed  in  this 
affection  (disorders  of  the  tendon  and  pupillary  reflexes, 
of  the  internal  secretions,  and  of  the  general  nutrition) 
is  increasing  from  day  to  day;  dementia  prsccox  is 
therefore  looked  upon  not  as  a  purely  mental  affection, 
but  as  an  affection  of  the  entire  organism  with  con- 
comitant   manifestations    which    are    chiefly,    but    not 


INTRODUCTION.  xi 

exclusively,  mental.  Such  is  also  the  case  with  primary 
mental  confusion  and  with  the  melancholias,  and  the 
time  is  not  remote  when,  with  great  benefit  to  psy- 
chiatry, the  conception  of  the  vesanias  will  be  rele- 
gated to  history. 

Two  terms  still  remain  for  us  to  define:  mental 
alienation  and  insanity.  Although  they  are  often 
employed  indiscriminately,  their  meaning  is  not  abso- 
lutely identical. 

Etymologically,  an  alienated  (Lat.  alienus)  indi- 
vidual is  one  who  has  become  " estranged"  from  him- 
self, who  has  lost  the  control  of  his  intellectual  activity, 
who,  in  other  words,  is  not  responsible  for  his  actions. 
Unfortunately  this  definition  rests  upon  the  meta- 
physical conception  of  the  free  will  and  cannot  find  a 
place  in  medical  science,  which  must  be  based  upon 
observation  and  must  adhere  to  demonstrable  facts. 

It  is  better  to  adopt  an  essentially  practical  definition, 
as  has  been  done  by  most  modern  alienists,  and  to 
designate  by  the  term  mental  alienation  the  entire  class 
of  pathological  states  in  which  the  mental  disorders, 
whatever  their  nature  be  otherwise,  present,  an  anti- 
social character.  Not  every  individual  suffering  from 
a  psychic  affection  is  necessarily  alienated.  This  term 
can  be  applied  only  to  those  who,  on  account  of  some 
mental  disease  or  infirmity,  are  likely  to  enter  into 
conflict  with  society  and  to  find  themselves,  in  con- 
sequence, unable  to  be  an  integral  part  of  it. 

The  term  insanity  has  a  more  restricted  meaning 
than  mental  alienation.  Generally  it  is  applied  to 
states  of  mental  alienation  which  result  from  a  psy- 
chosis, i.e.,  in  which  the  mental  disorder  is  an  expres- 


xn  INTRODUCTION. 

sion  of  an  active  pathological  process.  An  idiot  or  a 
clement  is  alienated  but,  except  in  cases  presenting 
complications,  not  an  insane  person. 

This  manual  is  divided  into  two  parts.  The  first 
part  treats  of  general  psychiatry  and  comprises  a  study 
of  the  causes,  symptoms,  and  treatment  of  mental 
disorders,  considered  independently  of  the  affections 
in  which  they  are  encountered.  The  second  part  is 
devoted  to  special  psychiatry,  that  is  to  say  to  the  study 
of  the  individual  psychoses.  It  has  been  thought 
advisable  to  devote  a  considerable  space  to  general 
psychiatry,  at  least  as  far  as  the  limits  of  this  work 
would  allow.  A  precise  if  not  an  extensive  knowledge 
of  the  most  important  elementary  psychic  disturbances 
would  seem  to  be  altogether  indispensable  for  a  full 
understanding  of  the  genesis  and  evolution  of  the 
psychoses. 


MANUAL    OF    PSYCHIATRY. 


PART  I. 
GENERAL  PSYCHIATRY. 


CHAPTER  I. 
ETIOLOGY. 

"On  studying  closely  the  etiology  of  mental  diseases 
one  soon  recognizes  the  fact  that  in  the  great  majority 
of  cases  the  disease  is  produced — not  by  a  particular 
or  specific  cause,  but  by  a  series  of  unfavorable  con- 
ditions which  first  prepare  the  soil  and  then,  by  their 
simultaneous  action,  determine  the  outbreak  of  in- 
sanity." 1 

An  individual  of  neuropathic  ancestry  and  himself 
tuberculous,  alcoholic,  and  exhausted,  has  an  attack 
of  melancholia.  Shall  we  attribute  the  attack  to  the 
exhaustion,  alcoholism,  tuberculosis,  or  heredity  f  It  is 
probable  that  all  these  enter  into  the  causation  of  the 


Griesinger.    Die  Pathologie  und  Therapie  der  Geisteskrankheiten. 


2  MANUAL  OF  PSYCHIATRY. 

attack,  but  it  is  difficult  to  determine  the  part  played 
by  each  of  them  and  to  isolate  the  specific  pathogenic 
agent.  While  it  is  justifiable  to  distinguish  theoreti- 
cally predisposing  causes  and  determining  causes  in 
psychiatry,  it  is  very  difficult  to  decide  whether  any 
given  cause  belongs  to  the  one  or  to  the  other  group. 
The  same  pathogenic  agent,  for  instance  alcohol,  may 
in  one  case  create  a  predisposition  which  is  brought 
into  play  by  some  subsequent  causative  factor;  in 
another  case  it  merely  brings  out  pre-existing  predispo- 
sition. 

The  subdivision  of  the  causes  of  mental  diseases 
into  two  groups,  one  comprising  the  predisposing 
causes  and  the  other  the  determining  causes,  is  there- 
fore merely  schematic.  But  as  it  has  many  advan- 
tages from  a  didactic  standpoint,  it  is  adopted  in  this 
work,  the  reader  being  again  reminded  that  such  sub- 
division is  more  or  less  arbitrary. 

§  1.  Predisposing  Causes. 

"  Mental  diseases  require  for  their  development  a 
soil  in  an  especially  modified  condition  of  long  stand- 
ing." 1  The  mind  does  not  succumb  to  the  pathogenic 
action  of  the  causes  which  we  shall  study  later  on  as 
determining  causes,  unless  its  power  of  resistance  is 
below  the  normal.  A  predisposition,  latent  or  apparent, 
congenital  or  acquired,  is  necessary  for  a  mental  disease 
to  originate  and  develop.  Properly  speaking,  psychoses 
of  the  cerebrum  validum  do  not  exist.     The  predisposing 

1  Joffroy.  De  V  aptitude  convulsive.  Gazette  hebdomadaire  de 
medecine  et  de  chirurgie,  11  fevrier  1900. 


ETIOLOGY.  3 

causes  therefore  play  an  essential  part  in  the  etiology 
of  mental  diseases.  They  are  classified  into  general 
and  individual. 

General  predisposing  causes.  —  The  action  of  the 
general  predisposing  causes  is  exerted  upon  commu- 
nities, and  not  upon  isolated  individuals.  They  are: 
race,  climate,  social  position,  occupation,  age,  sex,  and 
civil  condition. 

The  influence  of  race  1  in  the  causation  of  psychoses 
is  little  known  on  account  of  the  absence  of  sufficient 
statistical  data.  The  Hebrew  race  is  said  to  furnish 
a  large  proportion  of  neuropaths  and  psychopaths. 
It  seems  that  among  some  races  certain  psychoses  are 
particularly  rare;  thus  general  paresis  is  of  very  excep- 
tional occurrence  among  Arabs  and  African  negroes. 

The  study  of  climate  likewise  gives  us  but  little 
definite  information.  While  it  is  indisputable  that  cer- 
tain affections,  such  as  cretinism,  appear  most  frequently 
in  certain  countries  (Valais),  it  is  on  the  other  hand 
altogether  conjectural  that  the  inhabitants  of  moun- 
tainous regions  are  more  liable  to  insanity  than  those 
of  the  plains,  as  has  been  stated  by  some  authors.2 

A  priori  it  seems  likely  that  the  climate  of  warm 
countries  exerts  a  debilitating  influence  upon  the  ner- 
vous system  and  thus  favors  the  development  of  mental 

VBuschan.  Einfluss  der  Basse  auf  die  Haufigkeit  von  Geisteskrank- 
heiten.  Read  at  the  Convention  of  German  alienists  at  Dresden, 
1894. — Meilhon.  La  folie  chez  les  Arabes.  Annales  medico- 
psychologiques,  1896,  T.  Ill  et  IV. — Goltzinger.  Les  maladies 
mentales  en  Abyssinie.  Revue  russe  de  psychiatrie,  1897,  No.  33. — 
Duncan  Greenlers.  Mental  diseases  among  the  natives  of  Southern 
Africa.     The  Journal  of  Mental  Science,  1895. 

2  Lombroso.     Uhomme  de  genie. 


4  MANUAL   OF   PSYCHIATRY. 

disorders,  especially  in  Europeans.  I  have  found  no 
statistics  proving  this;  but  an  argument  in  favor  of 
this  supposition  appears  to  me  to  be  in  the  fact  that  a 
much  larger  number  of  suicides  occurs  in  French  and 
English  troops  while  stationed  in  tropical  countries 
than  while  living  in  Europe.  While  in  France  itself 
the  number  of  suicides  in  the  army  is  29  per  100,000 
soldiers,  in  Africa  it  rises  to  69  for  the  same  number  of 
men.  In  the  English  army  the  proportion  is  23  to 
100,000  in  the  British  Isles,  and  48  in  India.1 

The  influence  of  the  seasons  has  been  more  carefully 
studied.  According  to  Gamier,2  who  has  taken  for 
the  basis  of  his  work  the  number  of  admissions  to  the 
special  infirmary  of  the  poorhouse  from  1872  to  1888, 
the  frequency  of  mental  alienation  attains  its  maxi- 
mum in  June,  and  its  minimum  in  January.  During 
spring  the  number  of  admissions  rises,  to  fall  again 
during  the  latter  part  of  summer  and  during  autumn. 
The  heat  is  evidently  not  the  only  factor,  since  the 
greatest  number  of  cases  does  not  correspond  with  the 
highest  temperature  of  the  year.3 

It  is  interesting  to  note  the  almost  complete  parallel- 
ism existing  between  the  annual  curve  of  mental  aliena- 
tion and  that  of  suicide.     The  statistics  of  Jeck,4  based 

1  Archives  de  medecine  et  de  pharmacie  militaire,  Nov.  1892. 

2  Gamier.     La  folie  a  Paris,  1890,  p.  18. 

3  "I  intentionally  omit  the  discussion  on  the  action  of  the  atmos- 
pheric conditions,  which  is  but  little  known.  Stormy  weather 
favors  the  occurrence  of  agitation  in  the  insane.  ...  As  to  the 
influence  of  the  lunar  phases,  it  is,  to  say  the  least,  entirely 
hypothetical."     V.  Toulouse.     Causes  de  la  folie,  p.  147. 

*  Selbstmord  und  Jahreszeit.  Frankfort  Gazette,  Sept.  24,  1898. 
Reviewed  in  Centralblatt  jilr  Nervenheilk.  u.  Psychiat.,  Dec.  20,  1898, 


ETIOLOGY.  5 

upon  about  100,000  cases  of  suicide,  show  us  that  the 
highest  point  of  the  curve  is  in  June  and  the  lowest 
point  in  February,  exactly  as  it  is  in  the  case  of  mental 
alienation. 

Social  factors  play  an  important  role  in  the  etiology 
of  mental  diseases,  as  may  be  seen  from  a  study  of  the 
history  of  the  negro  race  in  America.  Before  their 
emancipation  the  negroes  were  forced  to  hard  labor, 
but  were  beyond  the  intense  struggle  for  existence, 
had  no  cares,  and  were  governed  by  rigorous  rules  of 
morality ;  in  those  times  they  were  almost  totally  exempt 
from  mental  disorders.  "  Insanity  was  almost  unknown 
among  them."  l  Since  their  emancipation,  having  been 
given  not  only  the  rights  but  also  the  burdens  of  free 
men,  they  have  abandoned  themselves  without  restraint 
to  all  excesses,  and  mental  alienation  has  become 
implanted  in  their  race,  so  that  in  this  respect  they 
have  now  nothing  to  envy  their  former  masters. 

Civilization,  by  the  stress  that  it  imposes  upon  indi- 
viduals, by  the  physical  and  moral  want  that  is  hidden 
beneath  its  brilliant  exterior,  and  by  the  constantly 
increasing  migration  of  the  inhabitants  of  the  country 
toward  the  large  cities,  which  it  brings  about,  con- 
tributes to  the  production  of  predisposition  to  insanity. 
It  is  therefore  not  surprising  that  the  number  of  in- 
sane is  constantly  increasing  in  the  so-called  civilized 
countries.  However,  this  increase  is  not  as  considerable 
as  it  appears  at  first  giance;  for  its  accurate  estimation 
it  is  necessary  to  keep  in  mind  two  factors  that  are 


1  Witmer.     Geisteskrankheiten    bei    der    farbigen    Rasse    in    den 
vereinigten  Staaten.     Allgemeine  Zeitschrift  fur  Psychiatrie,  1891. 


6  MANUAL   OF   PSYCHIATRY. 

often  neglected,  viz.,  the  increase  of  the  population, 
and  the  housing  of  patients,  many  of  whom  in  former 
times  lived  at  large  and  did  not  enter  into  the 
statistics.  It  is  well,  therefore,  while  recognizing  the 
serious  character  of  this  increase,  not  to  exaggerate  its 
extent. 

According  to  Esquirol's  statistics  the  number  of 
unmarried  insane  exceeds  that  of  the  married  ones. 
Tolouse  states  that  many  individuals  remain  single 
because  they  are  already  abnormal,  and  in  many  cases 
they  subsequently  become  insane.  Celibacy  itself 
cannot  therefore  be  incriminated;  marriage,  on  the 
contrary,  brings  into  play  certain  factors  favoring  the 
development  of  mental  disorders, — in  men  by  the  in- 
creased strain  imposed  upon  them,  and  in  women  by 
the  various  accidents  which  motherhood  entails.1 

Illegitimate  children  seem  to  be  more  liable  to  in- 
sanity than  legitimate  ones.  This  is  partly  due,  un- 
doubtedly, to  the  anomalous  situation  in  which  society 
places  these  unfortunates;  but  in  many  cases  there  is 
also  a  hereditary  influence.  It  is  probable  that  the 
parents  of  illegitimate  children  are  often  abnormal 
(Joffroy ) . 

All  ages  do  not  equally  predispose  to  insanity.  Though 
rare  in  childhood,  by  reason  of  the  rudimentary  state 
of  the  psychic  functions,  mental  disorders  are,  however, 
not  unknown  in  that  period  of  life.2  Insanity  attains 
its  maximum  of  frequency  between  the  ages  of  thirty- 

1  The  influence  of  the  puerperal  state  is  to  be  considered  later 
on  with  some  detail. 

2  Manheimer.  Le  troubles  mentaux  de  Venfance,  1900. — Rodiet, 
JJalcoolisme  chez  V enfant. 


ETIOLOGY.  7 

six  and  forty  years  among  men, — when  the  struggle 
for  existence  is  most  intense, — and  between  the  ages  of 
twenty-five  and  thirty-five  years  among  women, — 
when  the  burdens  of  maternity  are  greatest. 

Two  other  periods  of  physiological  development  pre- 
sent an  increased  predisposition  to  insanity;  one  cor- 
responds with  the  age  of  puberty  (from  fourteen  to 
twenty-four  years),1  the  other  with  the  onset  of  senility 
(seventy  years,  according  to  Ziehen).2  Finally,  in 
women  an  increased  predisposition  is  noticed  at  the 
period  of  the  menopause. 

In  a  word,  all  those  periods  of  life  which  involve  a 
strain  of  the  organism  expose  the  individual  to  men- 
tal disorders,  whether  such  strain  be  due  to  the  physio- 
logical development  of  the  organism  or  whether  it  be 
imposed  upon  it  by  the  exigencies  of  life. 

The  occupations  involving  the  use  of  certain  poisons 
(lead,  phosphorus)  may  under  unhygienic  conditions 
favor  the  appearance  of  insanity.3  Railroad  employees 
furnish  a  large  proportion  of  general  paretics.  Per- 
haps, as  Huppert  says,  the  constant  jarring  of  the 
nerves  due  to  the  vibration  of  the  cars  is  to  be  held 
responsible  for  this;  or  it  may  be  due  to  the  heavy 
responsibility  which  rests  upon  the  employees  of  even 
the  lowest  grades,  as  is  suggested  by  Sprengeler;  or 
possibly  it  is  to  be  attributed  to  the  alcoholic  excesses 
so  frequent  among  this  class  of  people.4 

1  Ziehen.  Les  psychoses  de  la  puberte.  Congres  internat.  de 
m6decine,  Paris,  1900. — Marro.    Les  psychoses  de  la  puberte.     Ibid. 

2  Ziehen.     Psychiatrie,  p.  210. 

3  Quenzeil.  Ueber  Bleipsy chosen.  NeurologischesCentralblatt,1899. 

4  Hoppe.  Beitrag  zur  Kenntniss  der  progressiven  Paralyse. 
Allgemeine  Zeitschrift  fur  Psychiatrie,  Vol.  58,  No.  6. 


8  MANUAL  OF   PSYCHIATRY. 

Physical  and  moral  want,  isolation,  and  absence  of 
steady  occupation  are  among  the  predisposing  factors, 
and  often  constitute  potent  causes  of  relapse  in  re- 
covered patients  discharged  from  asylums. 

The  number  of  insane  is  almost  the  same  in  the  two 
sexes.  While  certain  etiological  factors,  such  as  stress 
and  alcoholism,  predominate  in  the  male  sex,  the 
puerperal  state  and  lactation  in  the  female  sex  re- 
establish the  equilibrium.  Possibly  the  number  of 
insane  women  even  slightly  surpasses  that  of  insane 
men. 

Individual  predisposing  causes. — The  predisposition 
to  contract  mental  disease  is  but  one  of  the  manifesta- 
tions of  a  more  general  pathological  condition  which 
has  been  designated  by  the  term  degeneration.  Degener- 
ation affects  the  entire  organism  and  constitutes  under 
its  different  forms — psychopathies,  neuropathies,  ar- 
thritic manifestations,  etc. — the  feature  of  a  large 
pathological  class  in  which  the  insane  constitute  but 
a  simple  group. 

The  predisposition  may  be  congenital  or  acquired. 
Though,  as  is  more  frequently  the  case,  degenerates  are 
such  from  the  day  of  their  birth,  still  one  may  become 
one  of  that  class  later  on  in  life,  as  a  result  of  infectious 
diseases,  of  intoxications,  or  possibly  of  a  defective 
mental  and  physical  education. 

11  Congenital  predisposition  exists  in  more  than  half 
or  in  about  two-thirds  of  the  insane." 1  A  morbid 
heredity  constitutes  its  most  frequent  cause,  but  not 
the  only  one.     Many  authors  confound  hereditary  with 

1  Morselli.     Manuale  delle  malattie  mentali,  p.  38. 


ETIOLOGY.  9 

congenital  predisposition;  wrongly,  however,  for  "One 
may  be  a  congenital  degenerate,  yet  not  one  by 
heredity."  x  By  heredity  is  understood  the  existence 
in  the  ascendants  of  a  normal  or  pathological  pecu- 
liarity which  is  transmitted  to  the  descendant.  But, 
for  instance,  a  mother  suffering  from  Bright's  disease, 
and  without  psychopathic  taint,  may  give  birth  to  a 
degenerate  son,  predisposed  to  mental  alienation.  This 
would  not  be  a  case  of  hereditary  predisposition  in  the 
true  sense  of  the  word,  and  still  it  is  one  of  congenital 
degeneration. 

Heredity  is  direct  when  it  passes  from  the  parent  to 
the  offspring;  atavistic  when  it  skips  a  generation;  col- 
lateral  when  the  direct  ascendants  have  been  spared  but 
the  defect  is  found  in  one  or  several  collateral  relatives. 
It  is  similar  when  the  anomaly  present  in  the  descendant 
is  the  same  as  that  in  the  ascendant;  in  the  opposite 
case  it  is  dissimilar.  The  latter  form  is  by  far  the  most 
frequent,  for,  as  Hunter  says,  "  There  are,  properly 
speaking,  no  hereditary  diseases,  but  only  a  hereditary 
predisposition  to  contract  them."  All  possible  evi- 
dences of  degeneration  are  observed  among  the  ascend- 
ants and  the  collateral  relatives  of  the  insane :  neuroses, 
psychoses,  organic  nervous  diseases,  defects  of  character 
and  morals  [criminality],  arthritic  manifestations,  gout, 
diabetes,  etc. 

Heredity  is  convergent  when  the  father  and  the  mother 
both  belong  to  families  of  degenerates.  The  relative 
frequency  of  this  form  reveals  the  curious  fact  that  there 
is  a  peculiar  mutual  affinity  among  psychopaths  (Fere). 

1  Fere.   JLa  Famille  nevropathique,  p.  38.     Paris,  F.  Alcan. 


10  MANUAL  OF  PSYCHIATRY. 

A  priori  this  accumulated  degeneration  would  seem  to 
give  rise  to  particularly  grave  consequences.  At  times 
it  produces  genius. 

It  is  to  convergent  heredity  that  the  bad  influence  of 
consanguinity  is  to  be  attributed.  Consanguineous  mar- 
riages do  not  create  the  defects,  as  is  the  general  belief 
among  the  laity ;  they  merely  accentuate  the  tendencies 
of  the  family,  whether  these  tendencies  be  good  or  bad, 
and  therefore  cannot  exercise  a  bad  influence  except 
in  degenerate  families.1 

Degeneration  has,  according  to  Morel,  a  tendency  to 
become  more  pronounced  from  generation  to  generation. 
The  final  product  of  this  retrogressive  evolution  is  the 
idiot,  who,  sexually  sterile,  or  placed  in  social  positions 
which  prevent  his  leaving  a  posterity,  constitutes  the 
last  offspring  of  the  degenerate  race.  This  progressive 
march  is  quite  frequently  encountered.2  The  law  of 
Morel 3  is,  however,  not  absolute ;  degeneration  may  be 
effectively  combated  in  the  individual  by  appropriate 
physical  and  moral  hygienic  measures,  also  by  favorable 
intermarriages.  If  all  families  presenting  hereditary  de- 
fects were  doomed  to  decay  and  death,  the  human  species 
would  long  ago  have  become  extinct. 

Degeneration,  without  being  hereditary,  may  result 
from  a  pathogenic  influence  acting  upon  one  of  the 
parents  at  the  moment  of  conception,  or  upon  the 
mother  during  pregnancy.  Thus  endogenous  or  exo- 
genous, acute  or  chronic  intoxications,  infectious  diseases, 

1  Peiper.  Consanguinitai  in  der  Ehe  und  deren  Folge  fiir  die 
DexcewJenz.     Allg.  Zeitschr.  f.  Psych.,  Vol.  58,  No.  5. 

2  Doutrebente.     Ann.  nu'd.  psych.,  1869,  II,  p.  385. 
-  Morel.     Traite  da>  maladies  ?nentales,  p.  575. 


ETIOLOGY.  11 

stress  and  violent  emotions,  by  their  action  upon  the 
parents,  often  become  causes  of  degeneration.  Chronic 
alcoholism  is  encountered  with  particular  frequency  in 
the  parents  of  psychopaths  and  neuropaths;  it  produces 
all  possible  forms  of  degeneration,  but  creates  more  par- 
ticularly a  special  morbid  disposition  which  Joffroy  has 
termed  the  convulsive  tendency.  Many  children  of  alco- 
holic parents  die  of  convulsions  at  an  early  age,  and 
of  those  who  survive  more  than  50%  become  epileptics.1 

Infectious  diseases  and  traumatisms  sustained  by  the 
mother  during  pregnancy  often  exert  a  harmful  influence 
upon  the  psychic  development  of  the  offspring;  and  the 
same  is  the  case  with  physiological  privations,  painful 
emotions,  etc.  The  " children  of  the  siege" — those  of 
the  Parisian  population  who  were  born  just  after  the 
siege  of  Paris  and  the  Commune — furnished  a  very  large 
proportion  of  individuals  predisposed  to  insanity. 

In  the  cases  of  twin  pregnancy,2  the  influence  of  the 
factors  of  degeneration  manifests  itself  frequently  in  an 
identical  manner  in  the  two  children,  who  present  at  the 
same  age  the  same  mental  disorders.3  It  is  probable 
that  twin  pregnancy  is  in  itself  a  cause  of  degeneration, 
the  nutrition  of  two  foetuses  being  effected  under  less 
favorable  conditions  than  that  of  a  single  fcetus. 

1  See  statistics  of  Martin  quoted  by  Joffroy.  De  V aptitude  con- 
vulsive. Gazette  hebdomadaire  de  medecine  et  de  chirurgie, 
11  fevrier,  1900. 

2  Serge  Soukhanoff.  Sur  la  jolie  gemellaire.  Ann.  med.  psych., 
sept.-oct.  1900. 

1  The  same  similarity  may  be  observed  in  children  of  the  same 
family  independently  of  twin  births.  (Trend.  Maladies  mentales 
familiales.  Ann.  mod.  psych.,  Janvier,  1900. — Fouqu6.  Maladies 
mentales  familiales.     These  de  Paris,  1899.) 


12  MANUAL  OF  PSYCHIATRY. 

All  the  causes  here  enumerated,  including  heredity, 
act  upon  the  germ,  the  embryo,  or  the  foetus,  producing 
an  anomaly  of  development.  The  pathogenic  influence 
is  exerted  not  only  upon  the  nervous  system,  the  resist- 
ance of  which  is  reduced  and  the  development  impeded, 
but  upon  the  entire  organism,  bringing  about  the  mal- 
formations which  we  shall  study  later  on, — the  physical 
signs  of  degeneration. 

Each  of  the  causes  which  we  have  enumerated  can 
produce  all  the  forms  of  degeneration,  and  it  is  conse- 
quently impossible  to  determine  the  character  of  the 
degenerative  disorder  from  a  study  of  the  pathogenic 
agency  which  caused  it.  This  proves  the  fact  that  the 
pathogenic  agent,  "  whatever  be  its  nature,  always  acts 
in  the  same  manner, "  namely,  "by  diminishing  the  em- 
bryogenic  energy."  "  There  is  therefore  nothing  sur- 
prising in  the  fact  that  degenerates  by  heredity  do  not 
differ  from  those  by  parental  nutritive  disorders,  since 
degeneration  results  generally  from  disorders  of  embryo- 
genesis,  which  are  ultimately  reduced  to  disorders  of 
nutrition."  1 

Acquired  predisposition  results  from  the  influence  of 
the  same  causes  which  bring  about  congenital  predis- 
position.2 But  its  action  is  exercised  directly  upon  the 
individual,  instead  of  indirectly,  through  the  medium  of 
his  progenitors.  The  younger  the  subject  the  more  deep- 
rooted  and  durable  is  the  predisposition  which  he  ac- 
quires. The  infectious  diseases  and  the  nutritive  dis- 
orders of   infancy  frequently  give  rise  to  cerebral  and 

1  Fere.     Luc.   tit,   p.   231. 

2  Toulouse.     Les  causes  de  la  folie,  p.  30. 


ETIOLOGY  13 

meningeal  complications  which  result  in  convulsions  and 
impede  the  development  of  the  nervous  system,  thus 
causing  either  an  actual  defect  or  a  predisposition  which 
may  not  become  manifest  until  much  later  in  life,  in 
some  cases  not  before  senility. 

Finally,  predisposition  may  be  acquired  during  youth 
or  adult  age.  The  later  their  action  the  more  difficult  it 
becomes  to  distinguish  the  predisposing  from  the  deter- 
mining causes.  Here  we  may  recall  the  hypothetical 
case  of  alcoholism,  mentioned  at  the  beginning  of  this 
chapter;  alcoholism  may  act  in  some  cases  as  a  predis- 
posing cause  and  in  others  as  a  determining  cause,  and 
it  is  not  always  possible  to  establish  with  certainty  its 
mode  of  action. 

§  2.  Determining  Causes. 

As  we  have  shown  above,  according  to  most  alienists 
all  the  insane  belong  to  the  class  of  individuals  present- 
ing a  neurotic  predisposition ;  it  does  not,  by  any  means, 
follow  from  this,  however,  that  all  those  who  are  pre- 
disposed become  insane.  Save  in  the  instances  in 
which  there  is  a  congenital  psychic  infirmity,  such  as 
idiocy,  moral  insanity,  or  epilepsy,  most  of  the  psychoses 
are  acquired  and  supervene  in  individuals  previously 
sound  in  mind  or  at  least  free  from  evident  and  grave 
mental  disorders.  Thus  we  are  forced  to  assume  that 
some  new  factor  must  cause  the  cropping  out  of  a  pre- 
viously latent  morbid  tendency. 

The  study  of  the  determining  causes  is  therefore  of 
great  practical  interest.  We  can  do  nothing  against 
a  predisposition  except  in  an  indirect  and  general  way, 


14  MANUAL  OF  PSYCHIATRY. 

by  means  of  physical  and  moral  hygienic  measures, 
the  effects  of  which  may  be  felt  only  by  the  coming 
generations.  The  determining  causes  are,  on  the  con- 
trary, directly  accessible;  in  many  cases  we  can  either 
remove  them  or  combat  them.  An  example  will  render 
this  idea  clearer:  Three  individuals  are  from  their 
birth  equally  charged  with  a  hereditary  predisposition. 
One  of  them  leads  a  quiet  and  regular  life,  free  from 
overwork  and  excesses.  In  him  the  predisposition 
remains  latent,  and  his  life  passes  without  the  occur- 
rence of  mental  disturbances.  The  second  becomes 
addicted  to  alcoholism  and  in  course  of  time  develops 
the  usual  signs  of  the  intoxication;  but,  conscious  of 
his  danger,  he  abandons  his  intemperate  habits  and 
recovers  his  health.  Lastly,  the  third  gives  himself 
up  to  the  same  excesses  as  the  second,  but,  instead 
of  stopping  in  his  fatal  descent  in  time,  he  remains  an 
inveterate  drunkard  and,  becoming  demented,  ends 
his  days  in  an  insane  asylum.  These  three  individuals 
have  had  very  different  fates,  because  the  first  has 
escaped  the  determining  cause,  the  second  was  prudent 
enough  to  combat  it,  while  the  third  has  entirely 
abandoned  himself  to  its  influence. 

The  determining  causes  may  be  subdivided  into 
physical  and  moral. 

Physical  determining  causes. — We  are  to  congratu- 
late ourselves  upon  the  present  activity  among  alien- 
ists and  neurologists  in  the  investigation  of  the  etiological 
relations  of  toxaemias,  auto-intoxications,  and  infections. 
We  shall  see  in  the  course  of  this  work  that  many  new, 
interesting,  and  important  data  have  already  been 
obtained  through  these  researches. 


ETIOLOGY.  15 

The  germs  of  infectious  diseases  elaborate  toxins  the 
action  of  which  does  not  differ  essentially  from  that 
of  chemical  poisons,  such  as  alcohol  or  cocaine.  The 
infectious  diseases  and  the  intoxications  therefore  form 
in  psychiatry  two  groups  that  are  very  closely  related 
etiologically  and  even  clinically. 

We  distinguish  mental  disorders  which  are  coincident 
in  time  with  the  infection  itself  from  those  that  follow 
it.  Only  the  former  present  specific  features  and  merit 
the  name  of  infectious  psychoses.  They  appear  some- 
times in  the  prodromal  period,  but  more  frequently 
they  supervene  at  the  height  of  the  disease,  and  become 
alleviated  or  aggravated  coincidently  with  the  other 
symptoms  of  the  infection. 

The  psychoses  which  follow  infectious  diseases  depend 
upon  the  general  exhaustion  which  accompanies  con- 
valescence. They  appear  chiefly  as  acute  confusional 
insanity  or  as  chronic  psychoses  terminating  in  dementia 
(dementia  prsecox).  In  the  latter  case  the  mental 
disease  usually  does  not  break  out  until  several  weeks 
or  even  several  months  have  passed  after  the  infectious 
disease.  I  have  seen  in  Joffroy's  clinic  a  case  of 
catatonia  which  appeared  three  months  after  a  very 
severe  attack  of  scarlet  fever.  Possibly  the  primary 
affection  brings  about  a  general  disorder  of  nutrition 
which  does  not  become  manifest  until  the  lapse  of  a 
period  of  greater  or  lesser  duration. 

The  confusional  insanity  and  the  chronic  psychoses 
which  follow  infectious  diseases  do  not  present  any 
special  features  and  do  not  deserve  to  be  classed  as 
independent  morbid  entities.  In  their  symptomatology 
and  evolution  they  are  identical  with  the  same  con- 


16  MANUAL  OF  PSYCHIATRY. 

ciitions  when  caused  by  traumatisms,  overwork,  auto- 
intoxications, and  other  agents. 

All  the  acute  infectious  diseases  may  give  rise  to 
mental  disorders :  the  eruptive  fevers,  septicaemia,  erysip- 
elas, typhoid  fever,  gonorrhoea,  etc.1  The  post-infectious 
psychoses  are  of  very  frequent  occurrence  after  in- 
fluenza. Well  recognized  since  the  epidemics  of  recent 
years,  they  present  no  specific  features,  as  was  pointed 
out  by  the  authors  who  were  the  first  ta  make  a  study 
of  them  (Pick,  Schmitz).2 

The  mental  disorders  often  seen  in  the  course  of  acute 
articular  rheumatism  are  always  the  consequence  of 
meningeal  complications  which  either  accompany  or 
alternate  with  the  articular  inflammations.3 

The  mental  disturbances  due  to  malarial  infection 
may  be  classified  in  three  groups.  In  the  first  group  are 
those  which  are  associated  with  the  attack  of  malaria; 
these  rightly  belong  to  the  febrile  deliria.  In  the 
second  are  those  which  take  the  place  of  a  febrile  at- 
tack, constituting  a  form  of  malaria  larvata.  In  the 
third  are  those  which  occur  as  complications  of  the 
cachexia  of  the  pernicious  forms. 

These  disturbances  present  no  pathognomonic 
features,   and  only  a  knowledge  of  a  history  of  the 


1  Joffroy.  Fievre  typhoide  et  folie.  Congres  de  M6decine  mentale, 
1891. — Colombani.  Troubles  psychiques  dans  les  affections  genito- 
urinaries  de  Vhomme.     These  de  Paris,  1900. 

2  Schmitz.  Ueber  Geistesstorungen  nach  Influenza.  Allg.  Zeitschr. 
f.  Psychiatrie,  1891. 

3  Griesinger.  Pathologie  und  Therapie  der  Geisteskrankheiten. 
— V.  Mabille  et  Lallemand.     Les  folies  diathesiques,  1891. 


ETIOLOGY.  17 

disease  and  the  recurrence  of  the  attacks  furnish  the 
possibility  of  making  a  diagnosis.1 

The  mental  disorders  of  hydrophobia  will  be  described 
separately. 

Among  the  chronic  infections  two  are  deserving  of 
special  consideration,  namely,  syphilis  and  tuberculosis. 

Syphilis,  as  we  shall  see  later  on,  is  a  factor  of  primary 
importance  in  the  etiology  of  general  paresis.  It 
may  also  cause  mental  disorders  by  the  localized  lesions 
which  it  gives  rise  to  (arteritis,  gummata,  areas  of 
meningeal  inflammation). 

The  frequency  of  tuberculosis,  especially  that  of  the 
lungs,  in  insane  asylums,  has  long  been  known.  Es- 
quirol  has  mentioned  its  frequency  in  melancholiacs. 
According  to  Hagen,2  mortality  from  tuberculosis  is 
five  times  as  frequent  among  the  insane  as  it  is  among 
the  mentally  sound;  in  France,  according  to  Brouar- 
del,  only  three  times.  More  recent  statistics  seem  to 
show  that  these  alarming  proportions  are  somewhat 
exaggerated.  According  to  Heimann,  pulmonary  tuber- 
culosis is  not  notably  more  frequent  in  the  popula- 
tion of  asylums  than  it  is  in  the  normal  population. 
It  cannot  be  denied,  however,  that  certain  psychoses, 
through  the  nutritive  disorders  which  are  associated  with 
them,  favor  its  development.     But  in  mental  alienation 


1  Lemoine  et  Chaumier.  Des  troubles  psychiques  dans  Vimpalu- 
disme.  Ann.  med\  psych.,  1887. — Krafft-Ebing.  Zur  Intermittenz 
Larvata.  Arbeiten  aus  dem  Gesammtgebiet  der  Psych,  und 
Neuropath.,  No.  I,  1897. — Daniel  Pasmanik.  Ueber  Malaria- 
Psy chosen.     Wiener  medic.  Wochenschrift,  1897,  Nos.  12   and   13. 

2  Quoted  by  Heimann.  Die  Todesursachen  bei  Geisteskrankheiten. 
Allg.  Zeitschr.  f.  Psychiatrie,  Vol.  LVII,  No.  4. 


18  MANUAL  OF  PSYCHIATRY. 

tuberculosis  is  not  merely  an  effect;    it  may  also  be  a 
cause. 

Chartier x  has  made  an  interesting  study  of  the  mental 
disorders  connected  with  tuberculosis.  He  distin- 
guishes four  classes  of  cases: 

(a)  The  pyschosis  originates  during  the  course  of 
consumption ; 

(b)  It  alternates  with  the  tuberculous  exacerbations, 
and  constitutes  a  sort  of  tuberculous  equivalent; 

(c)  It  appears  after  the  apparent  cure  of  the  pul- 
monary affection; 

(d)  It  develops  in  a  subject  tainted  with  latent 
tuberculosis,  i.e.,  tuberculosis  which  does  not  present 
the  usual  symptoms  of  pulmonary  invasion  by  the 
bacillus  of  Koch. 

In  England  a  special  clinical  form  has  been  described 
under  the  name  of  tubercular  insanity,  which  develops 
in  three  stages.  The  first  stage  is  marked  by  change 
of  character — "  unsociability,  irritability,  and  an  entire 
want  of  buoyancy  and  proper  enjoyment  of  life."  2  The 
second  stage  presents  the  acute  symptoms:  ideas  of  per- 
secution, maniacal  states.  The  third  stage  is  a  state  of 
semi-stupor.  Chartier,  though  admitting  the  existence 
of  such  a  form,  does  not  consider  it  as  specific,  and 
adheres  to  the  opinion  generally  accepted  in  France 
"  that  most  of  the  known  forms  of  mental  alienation  may 
be  observed  coincidently  with  latent  tuberculosis."  3 


1  Chartier.     De  la  phtisie  et  en  particulier  de  la  phtisie  latente  dans 
ses  rapports  avec  les  psychoses.     These  de  Paris,  1899. 

2  Clouston.     Clinical  Lectures  on  Mental  Diseases,  p.  510. 

3  Chartier.     Loc.   cit. ,  p.   70. 


ETIOLOGY.  19 

Symptomatically  tuberculosis  manifests  itself  most 
frequently  by  states  of  depression.1  This  is  comparable 
to  the  abnormal  sadness  so  often  noticed  in  tubercular 
patients  at  the  beginning  of  their  affection .  Whatever 
form  they  may  assume,  the  mental  disorders  probably 
always  indicate  the  same  pathogenesis,  and  result  from 
the  action  of  the  tubercular  toxine  upon  the  nervous 
system,  also  from  the  impairment  of  the  general  nutri- 
tion. 

Malignant  tumors  are  sometimes  accompanied  by 
mental  complications  which  usually  assume  the  form 
of  confusional  insanity.2 

All  the  intoxications,  exogenous  or  endogenous,  are 
capable  of  determining  the  occurrence  of  mental  dis- 
turbances; in  practice  some  of  these  toxic  agencies 
are  encountered  with  especial  frequency. 

Among  the  exogenous  poisons  the  action  of  which  is 
readily  exerted  upon  the  nervous  system  may  be  named, 
in  the  order  of  their  clinical  importance,  alcohol;  very 
far  behind  it  morphine;  and  still  less  important  car- 
bonic oxide,  lead,  mercury,  cocaine, z  etc.  Among  the 
intoxications  of  endogenous  origin,  or  autointoxications, 
may  be  mentioned  urcemia,  myxedema,  and  acromegaly.4' 


1  Dufour  et  Rabaud.  Bulletin  de  la  Societe  anatomique,  Mars, 
1S99. 

2  Klippel.  Les  accidents  nerveux  du  cancer.  Archives  gen.  de 
Medecine,  1892. 

3  Pellagra,  which  is  probably  a  toxic  disease,  may  be  complicated 
by  episodes  of  depression.  Among  the  poisons  which  are  apt 
to  give  rise  to  mental  disturbances  are  to  be  mentioned  further  bella- 
donna, salicylic  acid  and  its  derivatives,  the  thyroid  substance. 
(Marais,  These,  1900.)  ~ 

4Joffroy.     Sur    un    cas    d' acromegalic    avec    demence.     Progres 


20  MANUAL  OF   PSYCHIATRY. 

The  importance  attributed  to  the  auto-intoxications  is 
growing  from  day  to  day.  We  shall  see  that  accord- 
ing to  Kraepelin's  ingenious  conception  general  paresis 
is  classed  as  a  disease  caused  by  auto-intoxication. 
Many  cases  of  dementia  prsecox  seem  to  indicate  an 
analogous  pathogenesis. 

In  a  group  closely  related  to  the  preceding  are  the 
disorders  of  nutrition,  which  may  likewise  be  complicated 
by  psychic  disturbances.  Gout  occasions  the  occurrence 
of  mental  disorders  which  either  precede  or  follow  the 
attacks,  or  in  some  instances  replace  them,  consti- 
tuting veritable  metastases.1 

The  association  of  psychic  disturbances  with  diabetes 
has  long  since  been  noted  by  various  authors.  Before 
the  time  of  Marchal  cle  Calvi  glycosuria  was  generally 
thought  to  be  the  consequence  of  nervous  or  mental 
affections;  this  author  has  shown  that  the  relation  is 
reversed,  that  the  latter  states  are  the  effect  and  not  the 
cause.2 

Laudenheimer,3   in   a    highly   interesting    and   very 

medic,  fevrier,  1898. — Brunet.  Etat  mental  des  acromegaliques. 
These  de  Paris,  1899. 

1  Regis  et  Chevalier-Lavaure.  Des  auto-intoxications  dans  les 
maladies  mentales.  Congres  de  medecine  mentale,  1894. — Seglas. 
Paper  on  the  same  subject.  Ibid. — Mabille.  L 'albuminuric  chez 
les  arthritiques  et  les  auto-intoxications  dans  les  maladies  mentales. 
Ibid. — Von  Solder.  Des  psychoses  aigues  dans  la  coprostase.  Jahrb. 
f.  Psych.,  1898,  Nos.  1  and  2. — Delle  auto-intossicazioni  nella  Pato- 
genesi  delle  Neurosi  et  delle  Psichosi.  II  Manicomio  moderno, 
Vol.  XIV,  Xo.  3. 

2  Cotard.  Alienation  mentale  et  diabete. — Bernard  et  Fere.  Des 
troubles  mentaux  chez  les  diabetiques.     Arch,  de  neurol.,  1882, Vol.  IV. 

3  Rudolph  Laudenheimer.  Diabetes  und  Geistesstorung .  Berlin, 
klin.  Wochenschr.,  1898,  Nos.  21  and  24. 


ETIOLOGY.  21 

thorough  work,  divided  the  cases  in  which  diabetes  and 
mental  disorders  coexist  into  four  classes: 

(1)  The  diabetes  and  the  mental  disorders  coexist 
without  any  etiological  classes : 

(2)  The  diabetes  is  the  consequence  of  the  mental 
disease ; 

(3)  The  diabetes  is  the  cause  of  the  mental  disease ; 

(4)  The  diabetes  and  the  mental  disorder  are  two 
effects  of  the  same  outside  cause. 

Clinically  the  mental  disorders  of  diabetes  frequently 
assume  the  form  of  depression;  there  is,  however,  no 
absolute  rule  with  regard  to  this. 

Aside  from  true  diabetes,  simple  glycosuria  is  fre- 
quently encountered  among  the  insane ;  it  is  usually  in- 
termittent, and  follows  the  states  of  intense  agitation. 

Overwork,  inanition,  cachectic  diseases  are,  by  reason 
of  the  general  exhaustion  and  the  nutritive  disorders 
which  they  bring  about,  among  the  important  factors 
in  the  etiology  of  insanity.  Their  most  usual  clinical 
expression  is  acute  confusional  insanity.1 

Chronic  exhaustion  manifests  itself  psychically  in  the 
neurasthenic  states,  the  study  of  which  belongs  properly 
to  the  domain  of  neurology. 

Most  organic  lesions  are  capable  of  affecting  the  psychic 
functions.  Ursemic  insanity  shows  the  importance  of 
renal  lesions  in  the  etiology  of  mental  diseases.  The 
general  vascular  affections  (arteritis,  atheroma),  through 
their  interference  with  cerebral  nutrition,  are  the  prin- 


1  Coulon.  Du  role  des  arterites  dans  la  pathologie  du  sysVeme 
nerveux.  Congres  des  medecins  alienistes  et  neurologistes.  Angers, 
1898. 


22  MANUAL  OF  PSYCHIATRY. 

cipal  factors  in  the  senile,  alcoholic,  and  apoplectic 
dementias. 

Heart-disease  l  is  frequent  in  the  insane.  The  statis- 
tics of  Strecker,2  based  upon  1000  autopsies  performed 
in  insane  asylums,  show  that  61.7%  of  the  men  and 
42. 7% of  the  women  present  cardiac  lesions.  These  are 
quite  frequently  the  consequence  of  the  psychoses, 
especially  of  those  which  are  accompanied  by  chronic 
excitement  (Krafft-Ebing) .  Sometimes  also  they  pre- 
cede the  mental  trouble,  and  play  an  important  part 
in  the  causation  of  the  attack. 

Valvular  insufficiencies  and  changes  in  the  myocardium 
act  either  directly  by  giving  rise  to  disorders  of  the 
cerebral  circulation,  or  indirectly  by  bringing  about 
renal  and  hepatic  insufficiency. 

Everybody  is  acquainted  with  the  changes  of  dis- 
position which  sufferers  from  dental  caries,3  dyspepsia, 
or  liver  troubles 4  are  subject  to.  Diseases  of  the 
stomach,  intestine,  and  particularly  those  of  the  liver 
sometimes  engender  veritable  psychoses.  Such  is  also 
the  case  with  affections  of  the  generative  organs,  the 
importance  of  which,  though  of  late  much  exaggerated, 


1  Fischer.  Ueber  psychosen  by  Herzkrankheiten.  Allg.  Zeitschr. 
f.  Psychiatrie,  Vol.  LIV,  No.  6. — Pelgmann.  Toxamische  Delirien 
bei  Herzkranken.     Deutsche  medic.  Wochenschr. ,  1899,  No.  19. 

2  Strecker.     Virchow's  Archive,  Vol.   126. 

3  Leopold-Levi.  Hepatotoxhcmie  nerveuse.  Arch.  gen.  de  med., 
mai,  juin,  juillet,  1897. — Cullerre.  Hepatisme  et  psychoses.  Arch, 
de  neurol.,  now  1898. — Klippel.  Insvffisance  hcpatique  dans  les 
maladies  mentales.     Arch.   gen.    de  med.,   1892. 

4  Poinsot.  Creation  et  Jonctionnement  du  service  dentaire  a  Vasile 
Sainte-Anne  (asile  clinique).  Travaux  du  troisieme  Congres  den- 
taire international,  huitieme  section,  Paris,  1900. 


ETIOLOGY. 


especially  in  the  case  of  women,  is  none  the  less  real. 
Similarly,  functional  disorders  of  these  organs  may  be 
accompanied  by  disturbances  in  the  psychical  sphere. 

The  slight  mental  troubles  that  often  occur  in  the 
menstrual  periods  in  some  cases  assume  the  proportions 
of  veritable  psychoses.  The  onset  of  menstruation  in 
young  women  is  also,  at  times,  the  origin  of  a  more  or 
less  serious  psychopathic  process.  Various  mental 
troubles  may  make  their  appearance  at  this  age,  such 
as  the  periodic  psychoses,  dementia  precox,  hysterical 
attacks,  etc.1 

The  mental  disorders  accompanying  visceral  lesions 
were  formerly  called  reflex  insanities.  It  was  supposed 
that  an  impression  originating  from  the  diseased  organ 
and  transmitted  to  the  brain  disturbed  the  psychic 
equilibrium  and  gave  rise  to  insanity.  Esquirol  attached 
considerable  importance  to  displacements  of  the  trans- 
verse colon.  In  reality  the  pathogenesis  of  these  cases 
is  entirely  different,  and  consists  most  likely  in  an  auto- 
intoxication or  an  infection,  the  starting-point  of  which 
is  in  the  diseased  organ. 

The  puerperal  state  2  is  a  common  cause  of  mental 
alienation.  The  puerperal  psychoses  do  not  form  a 
homogeneous  group,  either  from  an  etiological  or  from  a 
clinical  standpoint.  The  cause  of  the  disorder  may  be 
either  infection,  or  autointoxication,  or  profound  anaemia 
following  a  hemorrhage.     These  diverse  factors  may  act 


1  Hegar.     Zur  Frage  der  sogenannten  Menstrualpsy  chosen.     Allg. 
Zeitschr.  f.  Psychiatrie,  Vol.  LVIII,  Nos.  2  and  3. 

2  Castin.     Des  psychoses  puerperales  dans  leurs  rapports  avec  la 
degenerescence  mentale.     These,  Paris,  1899. 


24  MANUAL  OF  PSYCHIATRY. 

simultaneously.  The  clinical  forms  are  most  frequently 
primary  mental  confusion  and  dementia  prsecox.  Some- 
times the  puerperal  state  merely  brings  to  light  a  latent 
psychosis  (epileptic,  hysterical,  or  periodic  insanity). 
In  other  words,  there  is  no  single  puerperal  insanity,  but 
"  insanities,  or  rather  psychoses  of  the  puerperum."  * 

The  puerperal  psychoses  proper  are  to  be  distinguished 
from  the  psychoses  of  pregnancy  and  from  those  of 
lactation.  The  first  are  the  most  frequent.  The  fol- 
lowing proportions  are  given  by  Aschaffenburg :  2  preg- 
nancy 22.7% ;  puerperal  state  (childbirth)  57.6% ;  lac- 
tation 17.7%. 

Traumatisms  are  often  mentioned  in  the  antecedents 
of  insane  patients.  It  is  not  always  easy  to  determine 
the  degree  of  their  influence,  for  generally  they  precede 
very  remotely  the  onset  of  the  psychosis.  Stolper  3 
distinguishes  three  groups  of  traumatic  psychoses: 

(1)  Trauma-psychoses:  the  traumatism  is  the  sole 
cause ; 

(2)  Predisposition-trauma-psychoses :  the  traumatism 
merely  brings  out  a  pre-existing  predisposition; 

(3)  Trauma-predisposition-psychoses:  the  traumatism 
creates  a  predisposition,  which  some  subsequent  cause 
develops  into  a  psychosis. 

In  reality  the  predisposition  is  present  in  all  forms  of 
psychoses,  traumatic  or  otherwise,  so  that  the  first  two 
groups  of  Stolper  fuse  into  one. 

1  Ballet.     Lecoiis  cllniques  sur  Us  ncvroses  et  les  psychoses 

3  Aschaffenburg.      Ueber   die  klinischen  Forrnen  der  Wochenbett- 

psychosen.     Allg.  Zeitschr.  f.  Psychiatrie,  Vol.  LVIII,  Nos.  2  and  3. 
3  Quoted    by    von    Muralt.     Katatonische    Krankheitsbilder    nach 

Kopfverletzungen.     Allg.  Zeitschr.  f.  Psychiatrie,  Vol.  LVII,  No.  4. 


ETIOLOGY.  25 

The  traumatic  psychoses  *  may  present  themselves 
under  an  infinite  variety  of  clinical  forms:  catatonia 
(von  Muralt),  general  paresis  (Vallon),  periodic  insanity, 
neurasthenia,  etc. 

Like  the  puerperal  psychoses,  the  post-operative  psy- 
choses have  a  complex  pathogenesis.2  They  may  result 
from  the  shock  of  the  operation  itself,  from  the  anaemia 
following  profuse  hemorrhage,  from  an  infection,  or  from 
a  medicinal  intoxication.  One  must  also  bear  in  mind 
the  anxiety  preceding  the  operation,  which  may  attain 
considerable  intensity,  especially  in  degenerates  (Joffroy). 

Clinically  the  post-operative  psychoses  assume  va- 
rious forms,  and  do  not  constitute  a  special  morbid 
entity. 

All  the  organic  nervous  diseases — tabes,  multiple  scle- 
rosis, focal  cerebral  lesions,  etc. — and  all  the  neuroses — 
epilepsy,  hysteria,  exophthalmic  goitre,3  chorea,4  paral- 
ysis agitans,  etc., — may  be  accompanied  by  mental 
disorders.  Focal  lesions,  epilepsy,  and  hysteria,  the 
psychic  manifestations  of  which  present  special  features, 
will  form  the  respective  subjects  of  special  chapters. 

Congenital  or  acquired  neurasthenia  constitutes  a  fa- 


1  Kaplan.  Kopftrauma  und  Psychose.  Transactions  of  the 
Psychiatrical  Society  of  Berlin.  Published  in  Centralblatt  f. 
Nervenheilkunde  und  Psychiatrie,  May  24,   1899. 

2  Truelle.  Etude  critique  sur  les  psychoses  dites  post-operatoires . 
These,  Paris,  1898. — Picque.  Du  delire  psychique  post-operatoire. 
Ann  medic,  psychol.  July  and  August,  1898. — Joffroy.  Folie 
post-operatoire.     Presse  medicale,  March  1898. 

3  Joffroy.  Des  rapports  de  la  folie  et  du  goitre  exophtalmique. 
Ann.  med.  psych.,  1890. 

4  Joffroy.  De  la  folie  choreique.  Sem.  medic,  1893. — Ladame. 
Troubles  psychiques  dans  la  choree  degenerative.     Arch,  de  Neur.,  1900. 


26  MANUAL  OF  PSYCHIATRY. 

vorable  soil  for  the  appearance  of  certain  transient  or 
permanent  psychical  derangements:  obsessions,  essen- 
tial anxiety,  etc.  Neurasthenic  disorders  are  always 
associated  with  psychasthenic  disorders,  which  may 
almost  approach  in  intensity  the  depression  of  melan- 
cholia. 

Finally  the  neuralgias  may,  according  to  Krafft- 
Ebing,1  engender  true  transient  psychoses. 

Moral  causes. — The  laity  is  apt  to  exaggerate  the 
importance  of  the  moral  factors,  often  mistaking  the 
first  symptoms  of  the  disease  for  its  cause.  It  is  often 
said  of  an  individual  that  jealousy  or  anger  has  driven 
him  insane,  while  in  reality  the  jealousy  or  the  anger 
is  the  first  sign  of  derangement  in  his  case.  One  may 
apply  to  these  passions  what  Fere  justly  said  concern- 
ing love,  "to  become  insane  from  love,  one  must  have 
the  love  of  an  insane." 

The  violent  emotions  do  play  a  part,  however,  in  the 
production  of  mental  disorders,  at  least  as  adjuvant 
causes.  I  had  under  my  care  a  precocious  dement 
whose  affection  began  several  weeks  after  a  fire  in 
which  she  nearly  perished. 

The  influence  of  prolonged  or  repeated  emotions  is 
still  more  evident.  Great  national  commotions  and 
wars  cause  an  increase  in  the  number  of  the  insane.  It 
is  true  that  the  part  played  by  the  emotions  is,  in  these 
cases,  difficult  to  establish.  Indeed  a  great  many  other 
causes  co-operate  with  them.  As  the  most  important  of 
these  may  be  mentioned  alcoholic  excesses,  stress,  and 
privations. 

1  Krafft-Ebing.  Arbeiten,  1897,  I,  p.  81,  and  Allgem.  Zeitschr.  f. 
Psychiatrie,  Vol.  LVIII,  Nos.  2  and  3. 


ETIOLOGY.  27 

Prolonged  anxiety,  constant  perplexity,  also  play  a 
certain  part  in  the  etiology  of  the  psychoses.  These 
phenomena,  seen  chiefly  in  weak-minded  individuals, 
are  frequently  in  themselves  the  symptoms  of  an  already 
established  psychopathic  state,  and  here  again  the  dan- 
ger exists  of  mistaking  the  effect  for  the  cause. 

Such  is  also  the  case  with  exaggerated  religious  prac- 
tices and  with  extreme  sensibility,  which  also  indicate  a 
defective  mental  state. 

Isolation  is  said  to  produce  mental  disorders  in  pris- 
oners. It  is  not  impossible  that  the  abolition  of  all 
relations  with  their  like  and  the  absence  of  any  occupa- 
tion capable  of  arousing  the  interest  exercise  an  un- 
favorable influence  upon  the  mental  condition  of  pris- 
oners. But  the  action  of  these  causes  should  not  be 
overestimated,  for  it  must  not  be  lost  sight  of  that  most 
prisoners  are  congenitally  abnormal,  and  that  in  some 
insanity  has  existed,  unrecognized,  before  their  im- 
prisonment.1 

Mental  disorders  may  be  communicated  from  one  in- 
dividual to  another.  This  constitutes  mental  contagion, 
and  is  to  be  attributed  to  suggestion  (induced  insanity 
of  the  Germans). 

Often  the  delusions  are  transmitted  to  only  one  indi- 
vidual; we  then  have  the  "delire  a  deux."  This  gen- 
erally occurs  in  the  following  manner:    one  individual 


1Kirn.  Allg.  Zeitschr.  f.  Psychiat.,  XVIII,  13— Riidin. 
Klinische  Formen  der  Gej  angniss-Psy  chosen.  Allg.  Zeitschr.  f. 
Psychiat.,  LVIII,  Nos.  2  and  3. — Taty.  Alicncs  meconnus  et 
condamncs.  Congres  de  medecins  alienistes  et  neurologistes, 
10th  Session,  Marseille,  1899. — Pactet  et  Colin.  Les  alicncs  devant 
la  justice.    Encyclopedic  des  aide-memoire. 


2S  MANUAL  OF  PSYCHIATRY. 

becomes  insane  and  communicates  his  ideas  to  some 
member  of  his  family  or  to  one  of  his  friends. 
The  latter,  who  is  always  congenitally  feeble-minded, 
accepts  them  without  question,  and  sometimes  even 
finds  proof  of  them  in  his  own  hallucinations.  His 
delusions  are  essentially  the  functions  of  the  first  indi- 
vidual; they  undergo  the  same  fluctuations,  and  dis- 
appear with  the  removal  of  the  influence  of  the  other 
patient.  The  mechanism  is  the  same  when  the  con- 
tagion spreads  itself  over  a  more  or  less  numerous 
group  of  individuals,  as,  for  instance,  in  psychoses  of  a 
religious  type.  In  all  the  reported  instances  such 
epidemics  become  rapidly  extinguished  upon  the  re- 
moval of  the  influence  of  the  leader.1 


1  Regis.  De  la  folie  a  deux.  These,  Paris,  1880. — Marandon  de 
Montyel.  La  folie  a  deux,  Gaz.  des  Hopit.,  1894. — Dervey. 
Remarks  upon  psychical  contagion  and  infection.  American  Journ. 
of  Insanity,  Oct.  1899. — Ninas-Rodriguez.  Epidemie  de  folie 
religieuse  au  Bresil.  Ann.  med.  psych.,  May-June,  1898. — Falret. 
Etudes  cliniques  sur  les  maladies  mentales  et  nerveuses,  Paris,  1890, 
p.  545. — Michel  Delines.  Les  emmures  de  Tornovo.  Analyse  d'un 
travail  de  Sikorski.     Revue  Scient.,  Sept.  3,  1898. 


CHAPTER  II. 
SYMPTOMATOLOGY.— DISORDERS    OF     PERCEPTION. 

INSUFFICIENCY    OF   PERCEPTION.— ILLUSIONS.— 
HALLUCINATIONS. 

"The  senses,"  says  Jean  Muller,  " inform  us  of  the 
various  conditions  of  our  body  by  the  special  sensa- 
tions transmitted  through  the  sensory  nerves.  They 
also  enable  us  to  recognize  the  qualities  and  the  changes 
of  the  bodies  which  surround  us,  inasmuch  as  these 
determine  the  particular  state  of  the  nerves."  l  The 
senses,  in  other  words,  are  the  means  through  which  we 
obtain  the  knowledge  of  our  own  bodies  and  of  the 
external  world. 

For  their  proper  functioning  are  necessary:  (1)  the 
reception  of  an  internal  or  an  external  impression  by  a 
peripheral  organ;  (2)  the  transmission  of  this  impres- 
sion to  the  brain;  (3)  its  elaboration  by  the  cortical 
cells,  which  transform  it  into  a  phenomenon  of  the 
consciousness:  first  sensation  and  then  perception. 
Only  the  latter  operation  is  of  interest  to  the  alienist. 

We  shall  study  in  succession: 

I.  Insufficiency  of  perception; 

II.  Illusions  (inaccurate  perceptions); 

III.  Hallucinations  (imaginary  perceptions) .    Halluci- 

1  Jean  Muller.     Manuel  de  Physiologie. 

29 


30  MANUAL  OF  PSYCHIATRY. 

nations  and  illusions  are  often  classed  together  under 
the  name  of  psychosensory  disorders. 

§  1.  Insufficiency  of  Perception. 

Insufficiency  of  perception  in  its  slightest  degree  may 
be  met  with  in  states  of  depression,  at  the  onset  of  con- 
fusional  states,  etc.  All  external  impressions  are  vague, 
uncertain,  and  strange.  The  patients  complain  that 
everything  has  changed  in  them  and  around  them: 
objects  and  persons  have  no  more  their  usual  aspect; 
the  sound  of  their  own  voice  startles  them. 

In  a  more  marked  degree  of  insufficiency  external 
impressions  no  longer  convey  to  the  mind  of  the  sub- 
ject any  clear  or  precise  idea;  questions  are  either  not 
understood  at  all,  or  understood  only  when  they  are 
very  simple,  brief,  energetically  put,  and  repeated 
several  times.  External  stimulation,  even  the  strong- 
est, is  but  vaguely  perceived  and  often  causes  no  re- 
action proportionate  to  its  intensity  or  appropriate  to 
its  nature. 

Finally,  complete  paralysis  of  one  or  several  forms 
of  psychosensory  activity  is  observed  either  in  con- 
nection with  profound  disorders  of  consciousness,  as  in 
confusional  insanity  of  the  stuporous  form,  or  by 
itself,  as  in  hysterical  amaurosis  or  deafness. 

Insufficiency  of  perception  constitutes  an  important 
element  of  clouding  of  the  consciousness,  which  will 
be  considered  later  on. 

Its  pathogenesis  is  closely  connected  with  disorders 
of  ideation.  The  normal  act  of  perception  really  con- 
sists of  two  elements:    (1)  a  sensory  impression;    (2)  a 


SYMPTOMATOLOGY.  3 1 

series  of  associations  of  ideas  which  enable  the  mind 
to  recognize  the  impression  and  which  almost  always 
complete  it  and  renders  it  more  definite.  If  the  second 
operation  is  not  normally  effected,  the  sensations  remain 
vague  and  undecided,  and  there  is  insufficiency  of  per- 
ception. 

§  2.  Illusions  (Inaccurate  Perceptions). 

An  illusion  may  be  defined  as  a  perception  which 
alters  the  qualities  of  the  object  perceived  and  pre- 
sents it  to  the  consciousness  in  a  form  other  than  its 
real  one.  An  individual  who  hears  insulting  words 
in  the  singing  of  birds  or  in  the  noise  of  carriage-wheels 
experiences  an  illusion. 

Illusions  are  of  frequent  occurrence  in  normal  indi- 
viduals. There  is  no  one  to  whom  the  folds  of  a  cur- 
tain seen  in  semi-darkness  did  not  appear  to  assume 
more  or  less  fantastic  shapes.  But  the  mind,  aided  by 
the  testimony  of  the  other  senses,  recognizes  the  abnor- 
mal character  of  the  image;  the  illusion  is  recognized 
as  such.  By  the  insane  it  is  on  the  contrary  taken 
as  an  exact  perception  and  exercises  a  more  or  less 
marked  influence  upon  all  the  intellectual  functions. 

Illusions  affect  all  the  senses  and  present,  in  the 
case  of  each,  features  analogous  to  those  of  hallucina- 
tions; I  shall  therefore  not  describe  them  here.  I 
shall  say  but  a  few  words  concerning  illusions  of  sight 
which  present  certain  peculiarities. 

Illusions  of  sight  may  occur  in  most  of  the  psychoses, 
but  are  chiefly  found  in  the  toxic  psychoses  and  in  the 
infectious  deliria.     When  these  illusions  are  pertaining 


32  MANUAL  OF  PSYCHIATRY. 

to  persons  they  are  known  as  "false  recognitions." 
Many  insane  individuals  see  among  their  fellow  patients 
or  among  the  staff  of  employees  of  the  institution  their 
relatives  or  friends.  This  form  of  illusions  sometimes 
attains  such  completeness  that  the  subject  may,  while 
at  the  hospital,  believe  himself  to  be  at  his  home. 

Illusions  are  very  apt  to  occur  in  the  midst  of  vague 
impressions:  those  of  hearing  in  the  presence  of  con- 
fusing noises,  and  those  of  sight  in  semi-darkness. 

Like  incomplete  perceptions,  inaccurate  perceptions 
or  illusions  are  the  consequence  of  a  disorder  of  idea- 
tion; abnormal  associations  replace  the  normal  ones, 
which  are  absent,  and  complete  the  image,  altering  it 
at  the  same  time. 

§  3.  Hallucinations  (Imaginary  Perceptions). 

"  A  person  who  has  an  inmost  conviction  of  a  sensa- 
tion actually  perceived,  when  no  external  object  capable 
of  exciting  such  sensation  is  within  reach  of  the  senses, 
is  in  a  state  of  hallucination"   (Esquirol). 

"By  hallucinations  are  understood  subjective  sensory 
images  which  are  projected  outwardly  and  which  in 
that  way  acquire  objectivity  and  reality"  (Griesinger) . 

"'A  hallucination  is  a  perception  without  an  object" 
(Ball). 

These  three  definitions  are  essentially  identical.  That 
of  Ball  appears  to  me  to  be  the  best  on  account  of  its 
conciseness. 

Hallucinations  may  affect  any  of  the  senses.  There 
are  therefore  as  many  varieties  of  hallucinations  as 
there  are  senses. 


SYMPTOMATOLOGY.  33 

Some  properties  are  common  to  all  varieties  of  hal- 
lucinations, others  are  peculiar  to  each  variety. 

A.    PROPERTIES     COMMON   TO    ALL    VARIETIES    OF 
HALLUCINATIONS. 

Hallucinations  exercise  an  influence  upon  the  psychic 
personality  of  the  patient,  which  varies  with  the  sub- 
ject, the  nature  of  the  disease,  and  the  different  stages 
of  the  same  disease. 

In  a  general  way  it  may  be  stated  that  the  more 
acute  the  character  of  the  mental  disorder  (acute 
psychoses,  periods  of  exacerbation  in  chronic  psychoses) 
and  the  less  enfeebled  the  intellectual  activity,  the 
more  marked  is  the  influence  of  the  hallucinations. 
In  accordance  with  this  rule,  the  correctness  of  which 
is  clinically  demonstrated,  hallucinations  abate  in 
their  influence  as  the  acute  stage  of  the  psychosis 
subsides — either  when  the  patient  enters  upon  con- 
valence,  or  when  he  lapses  into  dementia;  under  such 
conditions  they  may  persist  for  a  greater  or  lesser 
length  of  time  without  exercising  any  influence  upon 
the  patient's  emotions  or  actions. 

The  influence  of  hallucinations  upon  the  psychic  func- 
tions.— Attention. — Hallucinations  force  themselves  upon 
the  attention  of  the  patient.  In  the  case  of  hallucina- 
tions of  hearing,  for  instance,  he  is  compelled  to  listen 
to  them,  sometimes  in  spite  of  himself,  no  matter  what 
their  degree  of  clearness  is, — whether  they  consist  of 
distinctly  spoken  words  or  phrases,  or  of  a  scarcely 
perceptible  murmur. 

The  patient  is  sometimes  conscious  of  the  tyrannical 
dominating  power  to  which  he  is  subjected.    "I  am 


34  MANUAL  OF  PSYCHIATRY.      - 

forced  to  listen  to  them/'  said  one  of  these  unfortu- 
nates; "when  they  (his  persecutors)  get  at  me  I  can 
do  no  work,  cannot  follow  any  conversation,  /  am 
wholly  in  their  power."  Hallucinations  thus  resemble 
the  imperative  ideas  and  the  autochtonous  ideas  which 
we  shall  study  later  on. 

Judgment. — Hallucinations  may  coexist  with  sound 
judgment  and  be  recognized  by  the  patient  as  a  patho- 
logical phenomenon.  They  are  then  called  conscious 
hallucinations.  Such  instances  are  not  very  rare  and 
consist  chiefly  of  hallucinations  of  sight.  A  celebrated 
case  is  that  of  Nicolai,  the  bookseller.  "The  visions 
began  in  1791,  after  an  omission  of  a  bloodletting  and 
an  application  of  leeches  which  he  underwent  habitually 
for  hemorrhoids.  All  of  a  sudden,  following  a  strong 
emotion,  he  saw  before  him  the  form  of  a  dead  person, 
and  on  the  same  day  diverse  other  figures  passed 
before  his  eyes.  This  repeated  itself  on  numerous 
occasions. 

"The  visions  were  involuntary  and  he  was  unable 
to  form  an  image  of  any  person  at  will.  Most  of 
the  time,  also,  the  phantoms  were  those  of  persons 
unknown  to  him.  They  appeared  during  the  day  as 
well  as  during  the  night,  assuming  the  colors  of  the 
natural  objects,  though  they  were  somewhat  paler. 
After  a  few  days  they  began  also  to  speak.  One 
month  after  the  onset  of  this  affection,  leeches  were 
applied;  on  the  same  day  the  figures  became  more 
hazy  and  less  mobile.  They  disappeared  finally  after 
Nicolai  had  for  some  time  seen  only  certain  portions 
of  some  of  them.'7 1 

1  Jean  Muller.     hoc  cit. 


SYMPTOMATOLOGY.  35 

Some  individuals  possess  the  power  of  producing 
their  hallucinations  at  will.  Goethe  had  that  power. 
"As  I  shut  my  eyes,"  he  said,  "and  lower  my  head 
I  figure  to  myself  a  flower  in  the  center  of  my  visual 
organ;  this  flower  does  not  retain  for  an  instant  its 
original  form;  it  forthwith  rearranges  itself  and  from 
its  interior  appear  other  flowrers  with  multicolored  or 
sometimes  green  petals;  they  are  not  natural  flowers, 
but  fantastic,  though  regular,  figures  like  the  rosettes 
of  the  sculptors.  It  is  impossible  for  me  to  fix  the 
creation,  but  it  lasts  as  long  as  I  desire  without  increasing 
or  diminishing."  1 

In  the  great  majority  of  cases  the  judgment,  itself  dis- 
ordered, is  unable  to  correct  the  psychosensory  error: 
the  hallucination  is  taken  for  a  true  perception.  Though 
sometimes  in  the  beginning  of  the  disease  the  subject 
experiences  some  doubts,  this  transitory  incertitude 
is  soon  replaced  by  a  blind  belief  in  the  imaginary 
perception.  "We  observe/'  says  Wernicke,  "that  the 
reality  of  the  hallucinations  is  maintained  against 
the  testimony  of  all  the  other  senses,  and  that  the 
patient  resorts  to  the  most  fantastic  explanations, 
rather  than  admit  any  doubt  as  to  the  accuracy  of  his 
perception."  2  An  individual,  alone  in  the  open  field, 
hears  a  voice  calling  him  a  thief.  He  will  invent  the 
most  absurd  hypotheses  rather  than  believe  himself  a 
victim  of  a  pathological  disorder. 

Certain  patients,  chiefly  the  weak-minded  and  the 
demented,  accept  their  hallucinations  without  inquiring 

1  Jean  Muller.     Loc  cit. 

2  Wernicke.     Grundriss  der  Psychiatrie,  p.   126. 


36  MANUAL   OF   PSYCHIATRY. 

as  to  their  origin  or  mechanism;  others  on  the  con- 
trary elaborate  explanations  which  vary  with  the 
nature  of  the  malady,  the  degree  of  the  patient's  educa- 
tion and  intelligence,  and  the  current  ideas  of  the  times. 
In  the  middle  ages  the  psychosensory  disorders  of  the 
insane  were  often  attributed  to  diabolic  intervention, 
and  this  not  only  by  the  patient  himself  but  also  by 
his  friends.  The  patients  of  our  own  times  mostly 
resort  for  explanations  to  the  great  modern  inventions 
(electric  currents,  telephone,  X-rays,  wireless  telegraphy, 
etc.).  Some  fancy  to  themselves  apparatus  or  imagi- 
nary forces.  One  patient  attributed  his  disturbances 
of  general  sensibility  to  a  "  magneto-electro-psychologic" 
current.  Another  received  the  visions  from  a  "theolo- 
gico-celestial  projector." 

Affectivity . — Hallucinations  are  sometimes  agreeable, 
at  other  times  painful,  and  occasionally,  chiefly  in 
dements,  indifferent. 

In  the  first  case  their  outward  manifestations  are  an 
appearance  of  satisfaction,  an  expression  of  happiness, 
and  sometimes  ecstatic  attitudes. 

In  the  second  case,  which  is  the  most  frequent,  the 
patients  become  sad,  gloomy,  or,  on  the  contrary, 
agitated  and  violent,  a  prey  to  anxiety  or  anger. 

The  two  kinds  of  hallucinations,  agreeable  and  pain- 
ful, are  occasionally  encountered  in  the  same  subject. 
Sometimes  they  follow  each  other  without  any  regular 
order  and  are  coupled  with  a  variable  disposition  and 
incoherent  delusions,  as  in  maniacs  and  in  general 
paretics;  at  other  times  they  follow  each  other  some- 
what systematically — the  painful  hallucinations  are 
combated    by    the    agreeable     ones.       The    patients 


SYMPTOMATOLOGY.  37 

often  speak  of  their  persecutors,  who  insult,  threaten, 
and  abuse  them,  and  of  their  defenders  who  con- 
sole them,  reassure  them,  and  repair  the  damage 
done  by  the  former.  A  persecuted  patient  heard  a 
voice  call  her  "a  slut";  immediately  another  voice 
responded,  "He  lies;  she  is  a  brave  woman."  Some 
patients  tell  of  their  limbs  being  smashed  and  their 
viscera  extracted  every  night,  but  that  nevertheless 
they  are  sound  and  safe  when  they  arise,  thanks  to  the 
good  offices  of  their  defenders,  who  properly  replace 
everything.  These  two  sets  of  hallucinations  con- 
stitute what  the  patients  sometimes  call  the  attack  and 
the  defense. 

The  indifferent  hallucinations  are  of  but  little  interest. 
They  are  met  with  at  the  terminal  periods  of  the  pro- 
cesses of  deterioration,  and  also  at  the  beginning  of 
convalescence  in  the  acute  psychoses.  In  the  latter 
case  they  rapidly  become  conscious  hallucinations  and 
finally  disappear.  - 

Reactions. — The  influence  of  hallucinations  upon  the 
will  depends  upon  the  state  of  the  judgment  and  of  the 
affect  ivity.  If  the  judgment  is  sound,  if  the  hallucina- 
tions are  looked  upon  as  pathological  phenomena,  they 
give  rise  to  no  reaction;  and  the  same  is  the  case  when 
they  make  no  impression  upon  the  emotions. 

But  when  they  are  accepted  by  the  patient  as  real 
perceptions  and  influence  strongly  the  emotional  state, 
hallucinations,  on  the  contrary,  govern  the  will  to  a 
very  considerable  extent  and  prompt  the  patient  to 
defend  himself  against  the  ill-treatment  of  which  he 
believes  himself  to  be  the  object  or  to  obey  the  com- 
mands which  are  given  him  (imperative  hallucinations). 


38  MANUAL  OF  PSYCHIATRY. 

Hence  the  frequency  of  violent  and  criminal  acts  com- 
mitted by  the  insane,  and  the  well-known  axiom  in 
psychiatry  according  to  which  all  subjects  of  hallucina- 
tions are  dangerous  patients. 

The  reactions  caused  by  hallucinations  are  often 
abrupt,  unreasonable,  and  of  an  impulsive  character, 
especially  in  the  feeble-minded  and  in  patients  with 
profound  clouding  of  consciousness  (delirium  tremens, 
epileptic  delirium).  But  they  may  also  show  all  the 
evidences  of  careful  premeditation.  Certain  perse- 
cuted patients,  exasperated  by  their  painful  hallucina- 
tions, prepare  their  vengeance  with  infinite  precau- 
tions. 

The  influence  of  hallucinations  upon  the  will  is  often 
so  powerful  that  nothing  can  combat  it,  neither  the 
sense  of  duty,  nor  the  love  of  family,  nor  even  the 
instinct  of  self-preservation.  A  patient  passing  near  a 
river  heard  a  voice  tell  him:  " Throw  yourself  into  the 
water."  He  obeyed  without  hesitation,  and  to  justify 
himself  declared  simply:  "They  told  me  to  do  it;  I 
was  forced  to  obey." 

Combined  hallucinations. — Sometimes  hallucinations 
affect  but  one  sense.  Such  are  the  hallucinations  of 
hearing  at  the  beginning  of  systematized  deliria.  Gener- 
ally, however,  the  pathological  disorder  affects  several 
senses,  the  different  hallucinations  either  following  one 
another,  or  existing  together  without  any  correlation, 
or  combining  themselves  and  producing  complex  scenes 
either  of  a  fantastic  aspect  or  analogous  to  real  life.  In 
the  latter  case  they  bear  the  name  of  combined  hallucina- 
tions. The  patient  sees  the  imaginary  persons,  hears 
them  speak,  feels  the  blows  that  they  inflict  upon  him, 


SYMPTOMATOLOGY.  39 

makes  efforts  to  reject  the  poisonous  substances  which 
they  force  into  his  mouth,  etc.  This  state,  closely  re- 
lated to  dreaming,  is  always  accompanied  with  marked 
clouding  of  the  intellect. 

Diagnosis  of  hallucinations. — Two  possibilities  may 
present  themselves:  (1)  The  patient  directly  informs 
the  physician  about  his  •condition;  (2)  He  gives  no 
information  whatever,  either  because  of  his  reticence  or 
because  of  his  intellectual  obtuseness. 

In  the  first  case  the  diagnosis  of  hallucinations  is  gen- 
erally easy.  It  is  necessary,  however,  to  ascertain  that 
the  pathological  phenomenon  is  really  a  hallucination, 
and  not  an  illusion;  in  other  words,  that  it  is  a  percep- 
tion without  an  object,  and  not  an  inaccurate  percep- 
tion. Only  a  detailed  examination  of  the  circumstances 
under  which  the  phenomenon  shows  itself  will  prevent 
the  error;  it  is  very  difficult  indeed,  when  a  subject  hears 
himself  being  called  a  thief  in  the  midst  of  thousands  of 
street  noises,  to  decide  whether  he  experiences  a  hallu- 
cination or  an  illusion.  The  certainty  is,  on  the  other 
hand,  much  greater  when  the  morbid  perception  occurs 
in  absolute  silence,  as  during  the  night,  for  instance. 

In  the  second  case  the  diagnosis  must  be  made  with- 
out the  assistance  of  the  patient,  or  even  in  spite  of  his 
denials.  It  must  be  based  only  upon  the  patient's  atti- 
tudes, movements,  and  at  times  upon  the  means  of 
defense  which  he  resorts  to  and  which  vary  according  to 
the  sense  affected.  The  ear  turned  for  some  time  in  a 
certain  direction,  the  eyes  fixed  or  following  a  definite 
line  without  there  being  any  real  object  to  attract  them, 
the  ears  stuffed  with  foreign  bodies,  evidences  of  strong 
emotions,  an  expression  of  fear,  etc.,  lead  to  the  pre- 


40  MANUAL  OF  PSYCHIATRY. 

sumption  of  the  existence  of  hallucinations.  I  say  pre- 
sumption  because  the  external  signs  do  not  enable  us  to 
establish  with  certainty  the  patient's  state  of  conscious- 
ness. Over-refined  psychological  analyses  are  to  be 
mistrusted  if  one  is  to  avoid  unwarranted  conclusions 
which  would  render  the  diagnosis  and  prognosis  faulty. 

Relations  between  hallucinations  and  other  mental 
disorders. — What  position  do  hallucinations  occupy  in 
the  genesis  of  the  psychoses?  Are  they  primary  or 
secondary? 

It  is  not  impossible  that  at  times,  notably  in  the  in- 
toxications and  in  cases  of  localized  lesion,  hallucina- 
tions appear  first  and  are  the  cause  of  the  other  mental 
disturbances  which  follow.  In  practice,  however,  such 
cases  occur  but  rarely.  A  careful  and  complete  history 
almost  always  shows  that  the  hallucinations  are  pre- 
ceded by  other  symptoms:  depression,  intellectual  ob- 
tuseness,  clouding  of  consciousness,  delusions,  etc. 

Indeed  it  is  difficult  to  conceive  of  one  or  more  hal- 
lucinations appearing  in  an  individual  free  from  all 
other  mental  trouble,  without  their  being  at  once  cor- 
rected by  the  judgment  aided  by  the  other  senses.  On 
the  other  hand  it  is  quite  intelligible  that  imaginary  per- 
ceptions may  exercise  an  influence  upon  the  attention, 
the  emotions,  the  judgment,  and  the  will,  if  they  are 
but  the  reflection  or  the  realization  of  the  patient's  pre- 
occupations and  morbid  ideas,  that  is  to  say,  if  they  are 
secondary.  The  melancholiac  who  believes  himself 
guilty  of  a  crime  sees  and  hears  the  police  officers  who 
are  coming  to  arrest  him.  The  persecuted  patient  who 
believes  himself  to  be  exposed  to  the  malevolence  of 
his  imaginary  enemies  hears  their  voices  insulting  him. 


SYMPTOMATOLOGY.  41 

The  general  paretic  with  pleasing  and  expansive  delu- 
sions experiences  pleasant  sensations.  Hallucinations 
are,  then,  the  expression,  and  not  the  cause,  of  delusions; 
and  that  is  why  they  harmonize  so  perfectly  with  the 
mental  state  of  the  subject. 

Some  alienists  l  have  described  a  hallucinatory  de- 
lirium as  a  distinct  morbid  entity  the  essential  features 
of  which  are  the  multiplicity  and  the  primary  character 
of  the  hallucinations.  If  the  idea  which  I  attempted  to 
expose  above  is  correct,  hallucinations,  never  or  almost 
never  being  primary,  cannot  form  the  essentialand  ex- 
clusive feature  of  an  affection,  and  hallucinatory  delirium 
cannot  retain  its  autonomy.  Therefore  most  authors 
classify  such  cases  with  confusional  insanity,  general 
paresis,  dementia  prsecox,  and  the  toxic  psychoses. 

General  etiology-  of  hallucinations. — On  this  subject 
we  possess  but  very  incomplete  information. 

Hallucinations  appear  readily  in  states  of  impaired 
consciousness,  as  epileptic  delirium  and  the  toxic  psy- 
choses. It  is  to  the  enfeeblement  of  consciousness  that 
the  hallucinations  induced  by  hypnotics  are  to  be  attrib- 
uted; these  hallucinations  precede  the  sleep  in  certain 
nervous  subjects  and  are  most  frequently  of  the  con- 
scious type. 

Hallucinations  are  very  apt  to  appear  in  the  absence 
of  real  sensations, — those  of  hearing  during  silence  and 
those  of  vision  in  darkness.  This  explains  why  isolation 
in  prison-cells,  practiced  in  penitentiaries,  predisposes 
to  hallucinatory  psychoses  (Kirn). 

In  some  instances  hallucinations  are  produced  in  a 

1  Farnarier.     La  psychose  liaUucinatoire,  Paris,  1S99. 


42  MANUAL  OF  PSYCHIATRY. 

somewhat  automatic  manner,  at  the  occasion  of  some 
definite  impression.  One  patient  felt  a  taste  of  sul- 
phur in  his  mouth  whenever  the  name  of  one  of  his  per- 
secutors was  uttered  in  his  presence.  Such  hallucina- 
tions have  been  described  by  Kahlbaum  under  the  name 
of  reflex  hallucinations. 

Hallucinations  may  depend  to  a  certain  extent  upon 
a  peripheral  excitation  either  of  the  sensory  organ 
itself  or  of  the  conducting  nerve.  They  are  in  such 
cases  frequently  unilateral.  "Max  Busch  has  brought 
about  a  notable  improvement  in  the  mental  condition 
of  a  patient  who  had  auditory  hallucinations  which  were 
most  marked  on  the  left  side,  by  treating  his  otitis 
media  with  perforation  of  the  drum  membrane,  which 
he  had  contracted  during  childhood."  x  Visual  hallu- 
cinations have  been  observed  to  appear  as  the  result 
of  ocular  lesions,  such  as  cataract,  and  to  disappear 
under  appropriate  treatment.  These  peripheral  lesions 
are,  so  to  speak,  but  a  pretext  for  the  hallucinations, 
and  are  not  to  be  considered  as  their  true  cause.  The 
cause  is  to  be  looked  for  in  the  special  state  of  morbid 
irritability  of  the  centers  of  perception  which  causes 
them  to  react  by  hallucinatory  phenomena  to  abnormal 
peripheral  excitation.2 

Peripheral  hallucinations  are  very  analogous  to  Liep- 
mann's  phenomenon:  if  in  a  convalescing  alcoholic- 
slight  pressure  is  made  upon  the  eyeballs,  hallucina- 

1  Quoted  by  Legay.  Essai  sur  les  rapports  de  Vorgane  auditif 
avec  les  hallucinations  de  Vouie.     These  de  Paris,  1898,  p.  25. 

2  Joffroy.  Les  hallucinations  unilaterales.  Arch,  de  neurol.,  1896, 
No.  2. — Mariani.  Un  cas  d' hallucination  unilaterale.  Riforma 
medica,  1899,  Nos.  30  and  31. 


SYMPTOMATOLOGY.  43 

tions  are  sometimes  induced,  even  when  the  subject 
does  not  any  more  experience  them  spontaneously. 
The  peripheral  excitation  transmits  to  the  brain 
nothing  but  a  nervous  discharge  the  clinical  expression 
of  which  is  the  hallucination.  The  fact  that  a  great 
many  patients  present  very  grave  and  old  standing 
lesions  of  the  sensory  organs  without  having  any  hallu- 
cinations is  also  evidence  of  the  fact  that  these  affec- 
tions are  of  but  secondary  importance  in  the  causation 
of  psychosensory  disorders. 

Finally,  hallucinations  may  be  induced  by  sugges- 
tion. Sometimes  it  suffices  merely  to  fix  the  attention 
of  the  patient  upon  a  certain  point  for  him  to  discover 
imaginary  objects,  persons,  or  forms.  Such  is  fre- 
quently the  case  with  the  intoxicated,  notably  alcoholics 
and  cocainomamacs,  also  with  certain  dements.  In 
an  observation  kindly  communicated  to  me  by 
Thivet,  a  patient  read  whole  words  upon  a  blank  sur- 
face that  was  presented  to  him. 

B.    SPECIAL     FEATURES     OF    EACH     VARIETY     OF    HALLU- 
CINATIONS. 

Hallucinations  of  hearing. — In  pathological  states,  as 
in  the  normal  state,  auditory  sensations  occupy  a  posi- 
tion of  primary  importance  among  the  psychic  func- 
tions; thus,  of  all  the  hallucinations  those  of  hearing 
are  clinically  the  most  frequent  and  the  most  important. 

Seglas  x    classifies    them   in   three   categories:   "The 

1  Lecons  diniques  sur  les  maladies  mentales  et  nerveuses,  p.  5. — 
Pathogenie  et  physiologie  pathologique  de  V hallucination  de  Vouie. 
Congres  des  medecins  alienistes  et  neurologistes,  1897. 


44  MANUAL   OF  PSYCHIATRY. 

elementary  auditory  hallucinations,  consisting  of  simple 
sounds;  the  common  auditory  hallucinations,  con- 
sisting of  sounds  referable  to  definite  objects;  and 
finally  verbal  auditory  hallucinations,  consisting  of 
words  representing  ideas." 

Wernicke  1  combines  the  first  two  categories  under 
the  name  of  akoasms,  and  designates  the  third,  the 
only  one  that  seems  to  him  to  merit  separate  considera- 
tion, by  the  name  of  phonemes. 

Akoasms  comprise  imaginary  noises  of  a  variable 
nature,  such  as  buzzing,  whistling,  screaming,  groan- 
ings,  ringing  of  bells,  explosions  of  firearms,  etc.  Their 
clinical  significance  is  the  same  as  that  of  hallucinations 
in  general,  and  their  influence  upon  the  mind  depends 
upon  their  interpretation  by  the  patient. 

Phonemes  (the  verbal  auditory  hallucinations  of 
Seglas)  have  on  the  contrary  a  special  significance,  in- 
asmuch as  they  consist  of  "  words  representing  ideas.". 
Their  influence  is  much  more  direct  and  much  more 
powerful  than  that  of  akoasms. 

Their  content  varies  from  isolated  words  to  the 
most  complicated  discourses.  Sometimes  the  words 
or  phrases  are  pronounced  indistinctly,  resembling  a 
faint  murmur;  at  other  times  they  are  perceived  with 
remarkable  clearness.  "It  seems  to  me,"  patients 
often  say,  "that  somebocty  is  speaking  very  near  me  . . . 
I  hear  my  enemies  as  well  as  I  hear  you."  This  dis- 
tinctness largely  accounts  for  their  being  accepted  as 
real  voices,  and  explains  partly  the  remarkable  influence 
of  auditory  hallucinations. 

xLoc.  cit.,  p.  189. 


SYMPTOMATOLOGY.  45 

The  "  invisible  ones/'  as  the  patients  often  call  the 
imaginary  voices,  are  sometimes  localized  with  extraor- 
dinary precision.  "The  insane  manifest  a  power  of 
localization  not  encountered  in  other  than  patho- 
logical states."  1  The  distance  at  which  they  believe 
they  hear  the  voices  is  very  variable;  the  voices  may 
be  very  close  by  or,  on  the  contrary,  hundreds  of  miles 
away.  Many  patients  hold  the  persons  that  are  around 
them  responsible  for  the  hallucinations;  thus  are 
explained  some  of  the  sudden  assaults  often,  com- 
mitted by  such  patients.  Others  ascribe  their  hallu- 
cinations to  inanimate  objects.  One  patient  accused 
her  needle,  another  her  stockings.  Still  others  lay 
the  blame  upon  invisible  instruments  which  are  used 
by  their  enemies  (phonographs,  telephones,  megaphones, 
etc.). 

Like  all  other  hallucinations,  those  of  hearing  vary 
with  the  nature  of  the  mental  trouble:  sad  in  the 
painful  states,  agreeable  and  cheerful  in  the  expansive 
states.  Usually  the  names  by  which  the  patients 
designate  the  " invisible  ones"  are  not  very  choice  ones, 
consisting  chiefly  of  profane  or  even  filthy  expres- 
sions. Unpleasant  hallucinations  may  alternate  with 
the  agreeable  ones  in  the  manner  of  attack  and  defense, 
as  has  already  been  stated.  Sometimes  each  of  the 
two  varieties  of  hallucinations  is  perceived  by  only 
one  ear. 

The  voices  may  repeat  the  thoughts  of  the  patient, 
even  before  he  has  a  chance  to  express  them.  "They 
know  before  I  do  what  reply  I  wish  to  make,"  said 

1  Wernicke.     Loc.  cit.,  p.  205. 


46  -  MANUAL  OF   PSYCHIATRY. 

one  such  patient.  Another  said:  "'When  I  read  they 
read  at  the  same  time  and  repeat  every  word."  Many 
complain  that  their  thoughts  are  stolen  from  them.1 

Quite  often  the  voices  create  neologisms  the  meaning 
of  which  may  remain  absolute^  enigmatical  to  the 
patient  himself,  or  to  which  he  may  attribute  a  signifi- 
cance which  harmonizes  with  his  psychical  state. 

The  timbre  of  the  voices  is  very  variable.  In  some 
cases  the  patient  always  perceives  one  and  the  same 
voice;  but  more  frequently  many  voices  are  heard: 
voices  of  men,  women,  and  children,  which  are  some- 
times unknown  to  the  patient,  at  other  times  familiar 
and  enabling  him  to  establish  the  identity  of  his  perse- 
cutors. 

Although  they  are  encountered  in  a  great  many  mental 
affections,  acute  and  chronic,  hallucinations  of  hearing, 
if  they  constitute  a  prominent  feature  by  reason  of  their 
multiplicit}^,  distinctness,  or  intensity,  usually  point 
to  a  grave  prognosis.  Their  occurrence  in  an  acute 
psychosis  often  forebodes  a  particularly  long  duration 
of  the  disease. 

Hallucinations  of  sight. — Hallucinations  of  sight 
chiefly  occur  in  toxic  and  febrile  deliria  and  in  certain 
neuroses  (hysteria,  epilepsy,  chorea). 

They  vary  greatly  in  distinctness.  At  times  they 
are  so  clear  that  the  patient  is  able  to  make  a  sketch 
of  them;  often  they  are,  on  the  contrary,  vague  and 
uncertain. 

Like  the  voices,  the  visions  are  apt  to  be  taken  for 


1  Bechterew.     Ueber  das  Horen  der  eigcnen  Gedanken.     Arch.  f. 
Psychiatrie,  Vol.   XXX. 


SYMPTOMATOLOGY.  47 

reality  by  the  subject;  he  seeks  to  remove  them,  to  shun 
them,  or  on  the  contrary  to  seize  them.  They  are 
in  such  cases  coupled  with  a  more  or  less  marked  cloud- 
ing of  the  intellect. 

Many  patients,  on  the  contrary,  consider  their  hal- 
lucinations as  artificial  phenomena.  The  more  con- 
scious and  the  clearer  in  mind  the  patient  is,  the  more 
apt  he  is  to  recognize  the  difference  between  the  real 
world  and  his  visions,  because,  with  the  exception 
of  the  cases  in  which  the  consciousness  is  profoundly 
disordered,  visual  hallucinations  "seldom  bear  the 
appearance  of  reality.'7  1  They  lack  the  proper  qualities 
of  normal  visual  sensations:  perspective,  clearness 
of  contour,  variety  of  tints,  etc.  Often  the  morbid 
image  appears  in  a  single  plane,  hazy  in  outline,  and 
grayish  in  color.  It  is  therefore  not  surprising  that, 
not  possessing  the  attributes  of  true  perceptions, 
visual  hallucinations  are  often  not  taken  for  reality, 
and  do  not  exercise  upon  the  mind  of  the  patient  the 
same  degree  of  influence  as  do  the  phonemes. 

Some  patients  consider  their  hallucinations  as  shadows 
or  images  which  they  are  made  to  see  artificially  by  means 
of  projecting  apparatus,  electric  currents,  etc.  Others 
attribute  them  to  the  pernicious  action  of  poisons 
which  their  enemies  make  them  absorb. 

Visual  hallucinations  may  take  the  form,  though 
rarely,  of  verbal  hallucinations  of  vision.  The  patients 
see  words  and  phrases  written  on  tables,  walls,  etc. 
A  subject  of  choreic  insanity  whom  I  have  observed 
in  Joffrov's  clinic  saw  hor  own  name  written  on  hor 


1  Wernicke.     Loc.  cit,,  p.  194. 


48  MANUAL   OF  PSYCHIATRY. 

apron.  Everybody  is  familiar  with  the  famous  words 
Mem,  mene,  tekel,  upharsin,  which  the  guests  saw  ap- 
pear upon  the  Avail  at  Belshazzar's  feast. 

Hallucinations  of  taste  and  smell. — The  senses  of 
taste  and  smell  are  as  closely  associated  in  pathological 
states  as  they  are  in  the  normal  state.  Therefore 
hallucinations  of  these  senses  are  usually  considered 
together. 

Their  clinical  significance  varies,  depending  upon 
whether  they  coexist  with  psychic  and  somatic  dis- 
orders of  an  acute  nature,  or  they  appear  in  the  course 
of  a  chronic  psychosis. 

In  the  first  case  they  often  result  from  the  dryness 
and  the  inflammation  of  the  nasal  and  buccal  mucous 
membranes  or  glands.  They  disappear  with  the  dis- 
turbances of  these  glands,  and  they  may  be  modified 
very  favorably  by  appropriate  treatment.  Their  im- 
portance with  regard  to  the  prognosis  in  such  cases  is 
very  slight. 

It  is  altogether  different  in  the  second  case,  when 
the}7  supervene  independently  of  the  above  causes  in 
the  course  of  chronic  affections.  They  almost  always 
indicate  a  profound  alteration  of  the  personality  and 
the  progress  of  the  mental  disorder  towards  dementia. 

Hallucinations  of  taste  and  smell  are  mostly  unpleas- 
ant. The  patients  complain  of  nauseating  odors; 
putrid  emanations  are  blown  towards  them;  they  are 
made  to  eat  fecal  matter;  poisons  are  poured  into 
their  mouth,  etc.  They  make  use  of  certain  means 
of  defense,  such  as  spitting,  stuffing  the  nostrils  with 
cotton  or  paper,  and,  what  constitutes  a  very  grave 
symptom,  refusal  of  food. 


SYMPTOMATOLOGY.  49 

Hallucinations  of  touch,  of  the  thermal  sense,  and  of  the 
sense  of  pain. — These  are  often  placed  in  a  single  group 
under  the  name  of  hallucinations  of  general  sensibility. 

Hallucinations  of  touch  are  frequent  in  certain  toxic 
psychoses  (delirium  tremens,  cocaine  delirium),  and 
in  chronic  systematized  deliria.  The  patients  feel  the 
breath  of  somebody  or  the  contact  with  something ;  they 
feel  as  though  spiders  were  crawling  upon  their  bodies, 
or  they  may  have  a  sensation  of  being  bound  in  an 
entangled  mass  of  cords. 

Closely  related  to  the  above  are  the  hallucinations  of 
the  genital  sense,  which  are  encountered  in  neuroses, 
chiefly  hysteria,  in  mania,  and  in  a  great  many  other 
acute  and  chronic  psychoses.  They  consist  of  either 
painful  or  voluptuous  imaginary  sensations.  When  they 
co-exist  with  perfect  mental  lucidity  they  generally 
indicate  a  very  grave  prognosis. 

Hallucinations  of  the  thermal  sense  and  of  the  sense  of 
pain  are  a  feature  of  chronic  systematized  deliria.  The 
patients  complain  of  being  burned  alive,  that  their 
body  is  being  pierced  with  a  red-hot  iron,  that  they  are 
being  thrown  off  from  their  chair,  that  they  are  made 
to  experience  shocks  like  those  of  electric  discharges,  etc. 

Motor  hallucinations. — A  motor  hallucination  may  be 
defined  as  an  imaginary  perception  of  movement.  It 
constitutes  a  disorder  of  that  kind  of  sensibility  which 
has  been  designated  by  the  term  muscular  sense. 

Analogous  phenomena  are  encountered  in  normal 
individuals:  the  sensation  of  heaviness  or  of  lightness 
of  the  limbs,  which  we  experience  during  sleep,  are  justly 
attributed  by  Beaunis  *  to   disturbances    of   the   mus- 

1  Les  sensations  internes,  1889,  Paris,  F.  Alcan. 


50  MANUAL  OF  PSYCHIATRY. 

cular  sense;   the  illusions  referred  to  an  amputated  limb 
are  often  accompanied  by  motor  hallucinations. 

Motor  hallucinations  are  frequent  among  the  insane. 
Some  feel  themselves  being  raised  from  their  bed,  being 
shaken  continually  against  their  will,  etc.  Others, 
like  the  mediaeval  sorcerers,  imagine  themselves  flying 
in  the  air. 

By  a  well-known  psychological  process  the  sensation 
tends  to  transform  itself  into  an  act,  the  motor  image 
into  a  movement.  The  motor  hallucination  becomes  an 
impulse.  The  patient  feels  with  astonishment  that  his 
limbs,  his  tongue,  or  his  mouth  become  the  seat  of 
movements  in  which  his  will  takes  no  part.  A  patient 
of  Krishabers,  for  instance,  felt  his  legs  "move  as 
though  endowed  with  a  power  other  than  that  of  his 
own  will."  Many  of  the  persecuted  or  mystic  patients 
affirm  that  they  have  been  transformed  into  automatons, 
and  that  God  or  their  enemies,  as  the  case  may  be,  can 
make  them  go  and  act  as  they  wish. 

There  is  a  certain  form  of  motor  hallucinations, 
which  deserves  particular  attention  by  reason  of  its 
frequency,  its  clinical  importance,  and  its  high  psy- 
chological interest;  these  are  the  verbal  motor  hallu- 
cinations which  have  been  admirably  described  by 
Seglas.1  As  their  name  indicates,  they  affect  the  func- 
tion of  speech.  The  patient  is  conscious  of  involuntary 
movements  of  his  tongue  and  lips,  identical  with  those 
which  produce  articulation  of  words.  The  sensation 
may  exist  alone  or  it  may  acquire  such  intensity  that 


1  Lecons  cliniques.     Also  Les  troubles  du  langage  chez  les  alienes. 
(Bibliotheque  Charcot-Debove.) 


SYMPTOMATOLOGY.  51 

it  is  transformed  into  actual  motion,  and  the  patient 
begins  to  speak  in  spite  of  himself.  Often  the  patho- 
logical movements  are  scarcely  apparent,  being  limited 
to  an  inaudible  whisper.  Sometimes  the  impulse  is  so 
strong  that  it  results  in  loud  talking  or  screaming. 
The  remarks  made  by  the  patient  in  such  a  case  may 
be  entirely  discordant  with  his  true  sentiments.  In 
this  way  such  patients  may  unintentionally  insult  their 
relatives,  making  use  of  obscene  language,  blasphemies, 
etc.  At  other  times  the  very  thoughts  of  the  patient 
are  spoken  out  in  spite  of  himself.  Pierr acini  has 
termed  this  phenomenon  "the  escape  of  thought. " 
(Quoted  by  Seglas). 

Verbal  motor  hallucinations  exercise  upon  the  function 
of  speech,  even  in  those  cases  in  which  they  do  not 
reach  the  stage  of  actual  articulatory  movements,  so 
powerful  an  inhibitory  influence  that  the  subject  be- 
comes totally  unable  to  speak.  This  is  in  perfect  accord 
with  the  observation  of  Strieker,  who  found  that  two 
verbal  motor  images  cannot  exist  at  the  same  time. 
Already  occupied  by  the  hallucinatory  motor  image,  the 
consciousness  remains  closed  to  normal  motor  images. 
Verbal  motor  hallucinations  are  thus  a  cause  of  mutism. 

Graphic  motor  hallucinations  affect  written  speech. 
"The  graphic  image  then  comes  into  play,  and  in  con- 
sequence of  the  morbid  irritability  of  the  special  cortical 
centre  for  written  speech  the  patient  has  the  exact  per- 
ception of  a  word  with  the  aid  of  the  representations  of 
the  co-ordinate  movements  which  would  accompany  it 
if  he  were  really  writing  the  word,"  l 

1  Seglas.     Les  troubles  du  langage,  p.  246. 


52  MANUAL  OF  PSYCHIATRY. 


/ 


AYhen  this  morbid  irritation  attains  a  certain  degree 
of  intensity  the  hallucination  becomes  a  graphic  impulse 
and  gives  rise  to  automatic  writing,  which  is  often  met 
with  in  the  "writing  mediums." 

The  interpretation  of  motor  hallucinations  varies  in 
different  patients.  Some  complain  that  their  enemies 
govern  their  tongues  by  means  of  invisible  wires.  Others, 
feeling  themselves  no  longer  masters  of  their  own  or- 
gans, are  naturally  led  to  think  that  a  strange  personality 
has  become  established  alongside  of  themselves.  Some 
of  the  "possessed"  of  the  mediaeval  times  undoubtedly 
had  motor  hallucinations. 

Motor  hallucinations  generally  involve  a  grave  prog- 
nosis. They  indicate  an  already  advanced  disaggre- 
gation of  the  personality.  Therefore  they  are  chiefly 
encountered  in  the  chronic  psychoses;  they  may  appear, 
however,  in  certain  acute  psychoses,  such  as  melan- 
cholia (Seglas)  and  alcoholic  systematized  delirium 
(Vallon,  Cololian).1 

Theories  of  hallucinations. — I  shall  but  mention 
the  so-called  psychological  theory,  according  to  which 
hallucinations  are  supposed  to  be  a  phenomenon  purely 
of  ideation.  Physicians  and  physiologists  have  long  ago 
abandoned  this  theory.  But  though  all  the  authors 
to-day  admit  the  existence  of  a  material  pathological 
process  as  the  foundation  of  hallucinations,  they  are 
far  from  being  in  accord  as  to  its  nature  and  as  to  its 
seat. 

Jean  Muller  is  of  the  opinion  that  hallucinations  are 

1  Cololian.  Les  hallucinations  psycho-motrices  verbales  dans 
Valcoolisme.     Arch,  de  Neurol.,  Nov.   1899. 


SYMPTOMATOLOGY.  53 

the  consequence  of  an  abnormal  irritation  of  the  periphe- 
ral sensory  organ. 

According  to  Meynert  they  result  from  the  automatic 
activity  of  the  subcortical  cerebral  centers,  which  are 
no  longer  inhibited  by  the  cerebral  cortex  as  they  are 
in  the  normal  state. 

The  primary  cause  of  hallucinations  would  thus  be  a 
suppression  of  the  inhibitory  power  of  the  cortex,  which 
is  one  of  the  manifestations  of  cortical  paralysis.  The 
hallucination  is  then  the  consequence  of  a  supremacy 
of  the  inferior  cerebral  functions  over  the  higher  ones. 

Finally,  according  to  Tambourini,  whose  opinion  is 
to-day  the  most  widely  accepted  one,  hallucinations 
are  produced  by  the  automatic  activity  of  a  psycho- 
sensory projection-center. 

Under  what  conditions  does  the  automatism  of  the 
projection-center  come  into  play?  Is  it  under  the 
influence  of  direct  irritation  resulting,  for  instance, 
from  a  tumor  or  from  a  circumscribed  patch  of  men- 
ingitis localized  exactly  at  this  center?  Such  cases  occur. 
Serieux1  has  observed  verbal  motor  hallucinations  in 
a  general  paretic  in  whose  case  the  autopsy  showed  a 
predominance  of  the  lesions  of  meningo-encephalitis  at 
the  level  of  the  lower  portion  of  the  left  third  frontal 
convolution.  The  lesion  must  not,  however,  be  a  too 
destructive  one.  "Indeed,  for  a  center  to  be  able  to 
produce  hallucinations,  it  is  necessary  that  conditions 
of  integrity  be  preserved  sufficient  to  permit  its  activity  " 
(Joffroy).2 

1  Sur  un  cas  d' hallucination  motrice  verbale  chez  une  paralytique 
generate.     Bull,  de  la  soc.  de  m£d.  merit,  de  Belgique,  1894. 

2  Les  hallucinations  unilaterales. — Siebert  has  also  reported  a  case 


54  MANUAL   OF  PSYCHIATRY. 

Most  frequently,  however,  the  center  of  projection  is 
not  the  seat  of  any  demonstrable  lesion.  It  seems,  then, 
that  in  most  cases  the  hallucinations  are  the  conse- 
quence, not  of  a  direct  irritation  of  the  psychosensory 
center  itself,  but  rather  of  an  indirect  irritation  coming 
from  another  portion  of  the  cortex.  This  explains 
why  hallucinations  are  always  a  secondary  phenomenon, 
and  why  they  are  but  an  expression,  a  reflection  of 
the  pathological  preoccupations  of  the  patient. 

Wernicke  has  conceived  a  very  ingenious  theory  of 
hallucinations,  founded  upon  his  general  hypothesis  of 
sejunction.  By  this  term  he  designates  a  temporary 
or  permanent  interruption  of  the  paths  followed  nor- 
mally by  a  nervous  impulse.  This  impulse  cannot 
pass  on  freely,  and  accumulates  above  the  point  of  the 
lesion  like  the  water  in  a  river  above  a  dam.  When 
this  accumulation  occurs  in  a  psychosensory  projection- 
center  it  determines  there  a  state  of  abnormal  irrita- 
tion of  which  the  clinical  expression  is  a  hallucination. 


in  which  very  pronounced  hallucinations  of  the  sense  of  smell 
persisted  for  a  long  time  and  subsequently  disappeared  by  degrees. 
At  the  autopsy  the  hippocampus  was  found  to  be  destroyed  by  a 
tumor.  The  author  supposes  that  the  hallucinations  were  caused 
by  irritation  of  the  center  in  question  by  the  growth,  and  that  they 
did  not  cease  until  this  center  was  destroyed.  (Monatschr.  fur 
Psych,  u.  Neurol.,  Vol.  VI.) 


CHAPTER  III. 

SYMPTOMATOLOGY   {Continued). 

CONSCIOUSNESS.  —MEMORY.  — VOLUNTARY  ASSOCIA- 
TIONS OF  IDEAS.— A  TTENTION.—A  UTOMA  TIC  ASSO- 
CIATIONS OF  IDEAS— JUDGMENT. 

§  1.  Disorders  of  Consciousness. 

The  consciousness  may  be  weakened,  resulting  in 
unconsciousness  or  in  clouding  of  consciousness;  or 
exaggerated,  causing  hyperconsciousness. 

Weakening  of  consciousness. — Unconsciousness  exists 
physiologically  in  dreamless  sleep,  and  pathologically 
in  coma  and  in  complete  stupor. 

Clouding  of  consciousness  represents  the  fundamental 
element  of  many  psychoses.  It  is  always  coupled  with 
more  or  less  complete  disorientation. 

A  complete  orientation  implies  the  integrity  of  the 
following  three  notions: 

1.  The  notion  concerning  our  own  personality  (auto- 
psychic  orientation  of  Wernicke) ; 

2.  The  notion  concerning  the  external  world  (allo- 
psychic orientation  of  the  same  author); 

3.  The  notion  of  time. 

These  three  notions  may  disappear  together  or 
singly.     We  shall  see  later  that  in  certain  affections, 

55 


56  MANUAL  OF  PSYCHIATRY. 

notably  in  delirium  tremens,  the  orientation  of  time 
and  place  is  lost,  while  that  of  personality  remains  intact. 
The  patient  is  ignorant  of  the  fact  that  he  is  in  a 
hospital  ward,  does  not  appreciate  his  surroundings,  and 
cannot  give  even  approximately  the  real  date.  But 
he  knows  that  he  is  Mr.  X.,  following  such  and  such  an 
occupation,  so  and  so  many  years  old,  born  on  such 
and  such  a  day,  etc. 

Allopsychic  disorientation,  or  loss  of  the  notion  of 
the  external  world,  is  often  coupled  with  many  hallu- 
cinations. Some  authors  see  in  the  two  symptoms  a 
causative  relation;  the  hallucinations  transport  the 
patient  to  an  imaginary  world,  thus  making  him  lose 
the  notion  of  the  real  world.  Experience  does  not  bear 
out  this  hypothesis:  1)  because  the  orientation  may  be 
perfectly  preserved  in  spite  of  intense  and  unceasing 
hallucinations;  2)  because,  inversely ,  it  may  be  pro- 
foundly disordered  without  there  being  hallucinations 
of  any  kind;  3)  because  in  most  of  the  cases  in  which 
these  two  symptoms  are  associated  the  disorientation 
precedes  the  psychosensory  disturbances. 

Influence  of  enfeeblement  of  consciousness  upon  the 
emotional  state  and  upon  the  reactions. — Unconscious- 
ness and  clouding  of  consciousness  find  expression,  in 
the  emotional  sphere,  in  indifference  and  dullness;  and, 
in  the  psychomotor  sphere,  in  aboulia  which  in  extreme 
cases  may  amount  to  complete  inaction. 

If  complicated  by  symptoms  of  excitement,  hallu- 
cinations and  illusions,  delusions,  or  anxiety,  clouding 
of  consciousness  is  accompanied  by  emotional  phenom- 
ena and  reactions  characteristic  of  each  of  these  states. 
It  is  important  to  remember  above  all  that  the  disorder 


SYMPTOMATOLOGY.  57 

of  consciousness  may  impart  to  the  reactions  of  the 
patient  a  more  or  less  impulsive  character;  hence  their 
brutal  and  sometimes  ferocious  nature. 

Diagnosis  of  enfeeblement  of  consciousness. — Uncon- 
sciousness is  generally  apparent  from  the  absolute 
indifference  of  the  subject  who  fails  to  react  even  to  the 
strongest  stimulation.  However,  it  is  necessary  to 
exercise  great  caution  in  many  cases.  We  shall  see 
later  on  that  certain  patients,  the  catatonics,  present 
all  the  appearances  of  unconsciousness  and  may  never- 
theless preserve  a  perfect  lucidity;  the  disorder  of  con- 
sciousness is  here  only  a  seeming  one.  Quite  often  one 
is  obliged  to  wait  before  making  a  decision;  when  the 
attack  passes  off,  the  patient  himself  may  tell  of  his 
former  condition,  either  declaring  that  he  has  no  recol- 
lection of  what  has  passed  during  the  attack, — in  which 
case  the  unconsciousness  was  real, — or  explaining  that, 
though  receiving  the  external  impressions,  he  was 
unable  to  react, — in  which  case  the  unconsciousness 
was  but  a  seeming  one. 

Clouding  of  consciousness  is  determined  by  putting 
to  the  subject  a  series  of  questions  concerning  his  age, 
his  occupation,  the  date,  the  surroundings,  and  the 
persons  about  him. 

States  of  obscuration. — By  this  term  are  designated 
those  pathological  states  in  which  the  disorder  of  con- 
sciousness is  the  dominant  feature.  States  of  obscura- 
tion vary  greatly  in  their  aspect,  and  probably  also  in 
their  nature.  All,  however,  possess  one  feature  in 
common:  they  leave  behind  them  an  almost  complete 
amnesia  for  the  occurrences  that  have  taken  place 
during  their  entire  duration.     But  the  state  of  con- 


58  MANUAL  OF  PSYCHIATRY. 

sciousness  at  the  time  of  the  attack  itself  is  very  diffi- 
cult to  determine,  and  probably  varies  greatly. 

Often  patients  afflicted  with  violent  delirium  have 
but  an  extremely  confused  notion  of  their  surroundings, 
and  their  acts  bear  the  character  of  complete  automa- 
tism.    Such  are  cases  of  epileptic  delirium. 

Others,  on  the  contrary,  perform  complicated  acts, 
such,  for  instance,  as  are  involved  in  a  long  voyage,  in 
a  sober  and  reasonable  manner  and  without  attracting 
anybody's  attention;  and  still  they  may  have  no  sub- 
sequent recollection  of  these  acts. 

It  can  scarcely  be  assumed  that  in  these  two  cases 
the  disorders  of  consciousness  are  essentially  identical. 

Exaggeration  of  consciousness.  —  Morselli  distin- 
guishes two  kinds  of  hyperconsciousness :  "  Hyper- 
consciousness  with  diffuse  introspection,  when  the  self- 
consciousness  is  referred  to  organic  phenomena,  giving 
rise  to  illusions  and  hallucinations  of  general  sensibility 
and  of  ccensesthesia  in  melancholiacs,  hypochondriacs, 
and  paranoiacs;  and  hyperconsciousness  with  con- 
centrated introspection,  when  representations  are  per- 
ceived and  emotions  experienced  with  an  abnormal 
intensity:  hence  the  ecstasy  of  spontaneous  or  induced 
(hypnotic)  hallucinatory  states."  1  Generally  hypercon- 
sciousness is  but  partial:  certain  sensations  or  certain 
representations  absorb  the  conscious  psychic  activity 
to  the  partial  or  complete  exclusion  of  others. 

1  Morselli.     Loc  cit.,  p.  754. 


SYMPTOMATOLOGY.  59 

§  2.  Disorders  of  Memory. 

An  act  of  memory  comprises  three  distinct  operations : 

1.  The  fixation  of  a  representation; 

2.  Its  conservation; 

3.  Its  revival,  that  is  to  say  its  reappearance  in  the 
field  of  consciousness. 

These  may  be  disordered  together  or  singly;  hence 
the  three  kinds  of  amnesia: 

A.  Amnesia  by  default  of  fixation  (or  simply  amnesia 
of  fixation),  also  known  as  anterograde  amnesia  ; 

B.  Amnesia  of  conservation; 

C.  Amnesia  of  reproduction. 

The  latter  two  affect  impressions  previously  acquired 
and  constitute  retrograde  amnesia;  there  are  there- 
fore two  varieties  of  retrograde  amnesia:  1)  by  default 
of  conservation,  and  2)  by  default  of  reproduction. 

A.  Amnesia  of  fixation.  Anterograde  Amnesia. — The 
power  of  fixation  (Merkjdhigkeit  of  German  authors)  is 
dependent  upon  the  distinctness  of  the  perceptions. 
Therefore  all  conditions  in  which  the  perceptions  are 
vague  and  uncertain  are  accompanied  by  a  more  or  less 
marked  amnesia  of  fixation;  such  is  the  case  in  the 
epileptic  deliria  and  acute  confusional  insanity. 

Distinctness  of  perception  is  therefore  a  condition 
necessary  for  the  normal  functioning  of  memory;  it 
is,  however,  not  in  itself  a  sufficient  condition.  An 
impression,  though  very  clear  and  very  precise  at  the 
moment,  may  not  fix  itself  upon  the  mind.  Thus  in 
the  polyneuritic  psychosis  the  patient  understands  per- 
fectly the  questions  put  to  him,  executes  properly  the 
orders  that  are  given  him,  so  that  on  a  superficial 


60  MANUAL   OF   PSYCHIATRY. 

examination  he  may  convey  the  impression  of  a  normal 
individual;  still  he  preserves  but  an  incomplete  recollec- 
tion, or  none  at  all,  of  the  occurrences  of  the  whole 
period  of  his  illness.  It  seems,  then,  that  for  proper 
fixation  is  required,  besides  sufficient  distinctness  of 
perception,  some  other  condition  the  nature  of  which 
is  as  yet  undetermined. 

B.  Retrograde  amnesia  by  default  of  conservation. — 
An  impression  fixed  in  the  memory  is  preserved  for  a 
greater  or  lesser  length  of  time,  depending  upon  its 
nature  and  upon  the  individual  capabilities  of  the 
subject.  The  memory  of  an  important  event  persists 
longer  than  that  of  an  insignificant  one.  Certain  indi- 
viduals possess  a  prodigious  memory,  others  a  very  poor 
one  or  almost  none  at  all;  between  these  two  extremes 
there  are  infinite  gradations. 

The  disappearance,  under  the  influence  of  some 
pathological, cause,  of  impressions  previously  acquired, 
constitutes  what  we  have  termed  amnesia  of  conserva- 
tion. This  destructive,  and  consequently  incurable, 
form  of  amnesia  is  the  principal  factor  of  dementia,  and 
is  often  the  first  sign  that  warns  the  patient's  friends 
and  relatives  of  the  approaching  condition. 

The  disappearance  of  impressions  may  be  more  or 
less  complete,  depending  upon  the  nature  of  the  dement- 
ing process.  While  many  precocious  dements  for  a 
long  tune  preserve  a  relatively  good  memory,  general 
paretics  and  senile  dements  present  from  the  beginning 
of  their  illness  a  very  marked  amnesia, 

Amnesia  of  conservation  is  generally  associated  with 
the  other  two  forms  of  amnesia:  amnesia  of  fixation 
and  amnesia  of  reproduction. 


SYMPTOMATOLOGY.  61 

C.  Retrograde  amnesia  by  default  of  reproduction. — 

In  the  normal  state,  an  impression  fixed  and  preserved 
in  the  memory  possesses  the  property  of  being  revived 
under  certain  conditions.  In  pathological  conditions 
this  power  of  reproduction  may  be  suspended:  the 
impressions  exist,  but  they  are  dormant  and  cannot 
be  revived.  This  form  of  amnesia  is  encountered  in 
many  acute  psychoses,  notably  in  manic  depressive 
insanity,  in  acute  confusional  insanity,  and  in  the 
toxic  psychoses.  Its  prognosis  is  of  course  much  more 
favorable  than  is  that  of  the  preceding  form. 

The  course  of  amnesia. — The  onset  may  be  sudden  or 
insidious;  it  is  often  sudden  in  amnesia  of  reproduction, 
— pure  or  associated  with  amnesia  of  fixation, — and 
almost  always  insidious  in  amnesia  of  conservation. 

Amnesia  may  be  stationary,  retrogressive,  or  pro- 
gressive; it  is  stationary  when,  certain  impressions 
having  become  destroyed,  the  defect  persists  without 
increasing;  retrogressive  when  the  impressions,  simply 
dormant,  reappear  little  by  little;  and  progressive 
when,  as  the  pathological  process  continues  to  act,  the 
number  of  destroyed  impressions  becomes  greater  from 
day  to  day. 

In  progressive  amnesia  the  disappearance  of  impres- 
sions occurs  not  at  random,  but  in  a  definite  order. 
"  The  progressive  destruction  of  memory  follows  a  logical 
course,  a  law.  It  descends  progressively  from  the  unstable 
to  the  stable:  it  begins  with  recent  impressions  which,  fixed 
imperfectly  upon  the  nervous  elements,  seldom  repeated 
and  therefore  but  feebly  associated  with  others,  represent 
the  organization  in  its  weakest  degree;  it  ends  with  that 
instinctive;  sensory  memory  which;  stably  fixed  in  the 


62  MANUAL  OF   PSYCHIATRY. 

organism  and  having  become  almost  an  integral  part  of 
it,  represents  the  organization  in  its  strongest  degree. 
From  the  beginning  to  the  end  the  course  of  amnesia, 
governed  by  the  nature  of  things,  follows  the  line  of 
least  resistance,  that  is  to  say,  the  line  of  least  organ- 
ization. "  1  In  senile  dementia,  in  which  the  law  of 
amnesia  is  most  perfectly  demonstrated,  the  impres- 
sions of  old  age  are  the  first  to  become  effaced,  later 
those  of  adult  life,  and  finally  those  of  youth  and 
childhood.  Some  of  the  latter  may  remain  intact 
long  after  the  general  ruin  of  the  memory  and  of  the 
other  intellectual  faculties.  It  is  not  uncommon  to 
meet  with  advanced  senile  dements  who,  though 
incapable  of  recollecting  the  existence  of  their  wife  and 
children,  are  still  able  to  relate  with  minute  details 
the  occurrences  of  their  childhood  or  to  recite  correctly 
fragments  from  the  works  of  classic  authors. 

The  law  of  amnesia,  though  always  the  same,  is 
most  difficult  to  demonstrate  in  those  affections  in 
which  the  enfeeblement  of  memory  progresses  very 
rapidly,  where  many  impressions,  like  other  manifes- 
tations of  intellectual  life,  disappear  en  masse.  In 
general  paresis  the  course  of  the  amnesia  is  much 
more  rapid  and  much  less  regular  than  in  senile  dementia. 
This  fact,  as  we  shall  see,  is  an  important  element  in 
diagnosis. 

Varieties  of  amnesia. — Amnesia  is  said  to  be  partial 
when  it  involves  only  one  class  of  impressions,  for 
instance  proper  names,  numbers,  certain  special 
branches    of    knowledge    (music,  mathematics),    or     a 

1  Ribot,      The  Diseases  of  Memory. 


SYMPTOMATOLOGY.  63 

foreign  language.  A  young  man  coming  out  of  a 
severe  attack  of  typhoid  fever  forgot  completely  the 
English  language,  which  he  had  spoken  fluently  before 
the  onset  of  the  illness.  Other  impressions  were  quite 
well  preserved.  When  it  involves  verbal  images  the 
amnesia  determines  a  particular  form  of  aphasia, 
amnesic  aphasia. 

Amnesia  is  general  when  it  affects  equally  all  classes 
of  impressions.  Most  of  the  progressive  amnesias  are 
general. 

Amnesia  may  be  limited  to  a  certain  period  of  exist- 
ence. In  such  cases  its  onset  is  almost  always  sudden, 
and  it  is  either  anterograde,  or  retrograde  by  default 
of  reproduction. 

Localization  of  recollections. — A  recollection  of  an 
occurrence,  once  evoked,  is  usually  easily  localized  by 
us  as  to  its  position  in  the  past.  This  power  of  locali- 
zation disappears  in  certain  psychoses.  The  patients 
cannot  tell  on  what  elate  or  even  in  what  year  some 
fact  occurred,  the  impression  of  which  they  have,  how- 
ever, preserved.  The  default  of  localization  in  the 
past  combined  with  a  certain  degree  of  anterograde 
and  retrograde  amnesia  produces  disorientation  of  time. 

Illusions  and  hallucinations  of  memory. — In  an  illu- 
sion of  memory  a  past  event  presents  itself  to  the 
consciousness  altered  in  its  details  and  in  its  relation 
to  the  patient,  and  exaggerated  or  diminished  in  im- 
portance. Thus  one  senile  clement  claimed  to  have 
superintended  the  construction  of  a  Gothic  cathedral 
several  centuries  old,  holding,  as  he  said,  "the  calipers 
in  one  hand  and  the  musket  in  the  other  to  defend 
myself  against  the  Saracens."      Upon  inquiry  it  was 


64  MANUAL  OF  PSYCHIATRY. 

found  that  the  patient  had  really  worked  about  thirty 
years  previously  at  the  restoration  of  an  old  cathedral. 

The  illusion  of  memory  becomes  a  true  hallucination 
when  the  representation  perceived  as  a  recollection 
does  not  correspond  to  any  actual  past  occurrence. 
A  patient  who  had  been  in  bed  during  several  weeks 
related  once  that  on  the  previous  day  he  assisted  at 
the  coronation  of  the  Russian  emperor:  this  is  a  repre- 
sentation without  an  object,  an  hallucination  of  memory. 

Illusions  and  hallucinations  of  memory  form  the 
basis  of  imaginary  reminiscences  1  which  are  met  with 
in  many  psychoses,  especially  in  hysteria  and  in  the 
polyneuritic  psychosis. 

I  shall  mention  lastly  a  curious  form  of  illusion  of 
memory,  which  has  been  designated  by  the  name  of 
"  illusion  of  having  previously  seen.  ...  It  consists 
in  a  be-ief  that  what  is  really  a  new  impression  for  the 
patient  was  previously  experienced  by  him,  so  that, 
though  it  is  produced  for  the  first  time,  it  appears  to 
him  to  be  a  repetition. ;;  2  One  patient  claimed  that 
all  the  occurrences  which  he  was  witnessing  had  taken 
place  a  year  previously,  day  by  day.  He  made  a 
great  deal  of  noise  at  the  marriage  of  one  of  his  sisters, 
demanding  to  know  why  a  ceremony  which  had  already 
been  performed  a  year  ago  was  begun  over  again,  and 
protesting  that  it  was  like  a  farce.3 


1  Delbriick.  Die  pathologische  Luge  und  die  psychisch  abnormen 
Schwindler. — Koeppen.  Ueber  die  pathologische  Luge  (Pseudologia 
phantastica).     Charite  Annal  ,  Jan.  1898. 

2  Ribot.     Loc,   cit. 

3  Arnaud.  Un  cas  d 'illusion  du  dejli  vu  ou  de  jausse  memoire. 
Ann.  mod.   p.sych.,  May-June,   1890. 


SYMPTOMATOLOGY.  65 


§  3.  Associations  of  Ideas  and  Attention. 

Associations  of  ideas  may  occur  as  the  result  either 
of  voluntary  ideation  or  of  the  activity  of  the  mental 
automatism. 

Voluntary  associations  of  ideas.  Attention.  —  The 
functions  of  attention  are:  1)  to  govern  the  associa- 
tions; 2)  to  regulate  the  course  of  representations, 
that  is  to  say  to  retain  each  of  them  for  a  greater  or 
lesser  length  of  time  in  the  field  of  consciousness;  and 
3)  to  inhibit  the  automatic  associations  which  may 
cause  a  deviation  of  the  course  of  voluntary  associations. 

Enfeeblement  of  attention  is  closely  connected  with 
a  sluggishness  of  the  voluntary  associations  of  ideas. 
This  latter  symptom  is  manifested  clinically  by  slowness 
of  apprehension,  and  experimentally  by  an  increase 
of  the  reaction-time,  that  is  to  say  the  time  required 
for  a  sensation  to  be  transformed  into  a  voluntary  and 
conscious  movement.1 

Enfeeblement  of  attention  and  sluggishness  of  volun- 
tary associations  constitute  the  earliest  and  most  con- 
stant manifestations  of  psychic  paralysis. 

Their  intensity  may  be  of  three  different  degrees: 

1st  degree:  diminished  capacity  for  intellectual 
exertion,  rapid  fatigue; 

2d  degree:   intellectual  dullness; 

3d  degree:  complete  suspension  of  all  voluntary 
intellectual  activity. 

Enfeeblement  of  attention  and  sluggishness  of  asso- 

1  Pierre  Janet.  Nevroses  et  idles  fixes,  Paris,  F.  Alcan. — Sommer. 
Lehrbuch  der  psychopalhologischen    Untersuchungsmethoden,  1899. 


66  MANUAL   OF   PSYCHIATRY. 

ciations  may  exist  alone,  as  in  certain  forms  of  melan- 
cholia, and  especially  in  stupor,  in  which  they  attain 
their  highest  degree.  They  may  also  be  associated 
with  an  exaggerated  activity  of  the  mental  automatism, 
which  manifests  itself  by  an  abnormal  mobility  of 
attention  and  by  a  flow  of  incongruous  ideas  (flight 
of  ideas,  incoherence),  or,  on  the  contrary,  by  the  ap- 
pearance in  the  field  of  consciousness  of  some  particu- 
larly tenacious  and  exclusive  representation  (impera- 
tive ideas,  fixed  ideas,  autochthonous  ideas). 

Abnormal  mobility  of  attention.1 — In  this  condition 
any  external  impression,  whatever  it  may  be,  suffices 
to  capture  the  patient's  attention,  but  nothing  can  fix 
it.     This  symptom  exists  in  its  purest  form  in  mania. 

Flight  of  ideas. — Incoherence. — These  two  symptoms 
constitute  two  different  degrees  of  the  same  morbid 
process. 

Flight  of  ideas,  almost  always  dependent  upon  an 
abnormal  mobility  of  attention,  is  constituted  by  a  rapid 
succession  of  representations  which  appear  in  the  field  of 
consciousness  without  any  order,  at  the,  occasion  of  ex- 
ternal impressions,  superficial  resemblances,  coexistences 
in  time  or  space,  similarities  of  sounds,  etc.  One  word 
arouses  the  idea  of  another  one  of  a  similar  sound  or 
having  the  same  termination  (association  by  assonance). 
The  following  example  from  the  case  of  a  maniac,  whose 
discourse  during  several  minutes  was  copied  verbatim, 
will  show,  better  than  a  description  could,  the  character 
of  this  pathological  phenomenon: 


1  It  results  from  an  exaggerated  activity  of  what  has  been  termed 
spontaneous  attention  in   contradistinction  to  voluntary  attention. 


SYMPTOMATOLOGY.  67 

" Now  I  want  to  be  a  nice,  accommodating  patient; 
anything  from  sewing  on  a  button,  mending  a  net,  or 
scrubbing  the  floor,  or  making  a  bed.  I  am  a  jack-of-all- 
trades  and  master  of  none!  (Laughs;  notices  nurse.) 
But  I  don;t  like  women  to  wait  on  me  when  I  am  in 
bed;  I  am  modest;  this  all  goes  because  I  want  to 
get  married  again.  Oh,  I  am  quite  a  talker;  I  work 
for  a  New  York  talking-machine  company.  You  are  a 
physician,  but  I  don't  think  you  are  much  of  a  lawyer, 
are  you?  I  demand  that  you  send  for  a  lawyer!  I 
want  him  to  take  evidence.  By  God  in  Heaven,  my 
Saviour,  I  will  make  somebody  sweat!  I  worked  by 
the  sweat  of  my  brow!  (Notices  money  on  the  table.) 
A  quarter;  twenty-five  cents.  In  God  we  trust;  United 
States  of  America;   Army  and  Navy  forever! " 

Flight  of  ideas  was  formerly  considered,  especially  in 
mania,  the  result  of  excessive  activity  of  the  normal 
intellectual  function;  it  was  believed  that  the. patient, 
unable  to  express  in  words  the  ideas  which  crowd 
themselves  into  the  consciousness,  is  compelled  to 
leave  out  a  large  number  of  them,  and  that  these  omis- 
sions cause  the  disconnectedness  of  his  discourse. 

In  reality  this  exaggerated  activity  affects  only  the 
automatic  intellectual  functions  and  is  always  associated 
with  an  enfeeblement  of  the  higher  psychic  functions. 
The  essential  cause  of  the  phenomenon  is  to  be  looked 
for  in  a  weakness  of  attention:  representation  A  can- 
not fix  itself  upon  the  consciousness  and  is  immedi- 
ately replaced  by  representation  B,  so  that  the  ideas 

fly- 
While  in  flight  of  ideas  the  representations  are  still 

associated  by  their  relations,  which  though  superficial 


68  MANUAL   OF  PSYCHIATRY. 

are  yet  real,  in  incoherence  they  follow  each  other 
without  any  even  apparent  connection.  The  following 
is  a  specimen  of  incoherent  speech  obtained  from  a 
case  of  dementia  prsecox:  "What  liver  and  bacon  is 
I  don't  know.  You  are  a  spare;  the  spare;  that's  all. 
It  is  Aunt  Mary.  Is  it  Aunt  Mary?  Would  you  look 
at  the  thing?  What  would  you  think?  Cold  cream. 
That's  all.  Well,  I  thought  a  comecliata.  Don't  worry 
about  a  comediata.  You  write.  He  is  writing. 
Shouldn't  write.  That's  all.  I'll  bet  you  have  a  lump 
on  your  back.  That's  all.  I  looked  out  the  window 
and  I  didn't  know  what  underground  announcements 
are.    My  husband  had  to  take  dogs  for  a  fit  of  sickness. " 

These  few  lines  suffice  to  show  the  profound  degree 
of  psychic  disaggregation  which  is  manifested  by  this 
phenomenon. 

It  is  not  infrequent  to  see  the  two  symptoms,  flight 
of  ideas  and  incoherence,  appear  in  succession,  or  even 
together  in  the  same  subject,  notably  in  cases  of  mania 
and  of  acute  mental  confusion. 

Imperative  ideas.  —  Fixed  ideas.  —  Autochthonous 
ideas.1 — We  have  stated  above  that  mental  automatism 
may  manifest  itself  by  the  appearance  of  an  idea  that 
is  particularly  tenacious  and  exclusive,  occupying  by 
itself  the  field  of  consciousness  from  which  nothing  can 
dislodge  it.2 

The  three  forms  under  which  this  phenomenon  may 
present  itself  have  been  well  defined  by  Wernicke.3 

1  Keraval.     L'idee  fixe.     Arch,  de  Neurol.,  1899,  Nos.  43  and  44. 

2  This  form  of  mental  automatism  may  be  termed  monoideal 
automatism. 

3  hoc.  ct.,  p.  108. 


SYMPTOMATOLOGY.  69 

An  imperative  idea  imposes  itself  upon  the  patient's 
consciousness  against  his  own  will;  he  recognizes  its 
pathological  character  and  seeks  to  rid  himself  of  it. 
It  is  a  parasitic  idea,  recognized  by  the  patient  as  such. 

A  mother  is  haunted  by  the  idea  of  killing  her  child 
whom  she  loves  dearly.  As  she  herself  states,  she  can 
no  longer  think  of  anything  else;  but  she  recognizes 
it  as  a  morbid  phenomenon  and  begs  to  be  relieved  of 
it:    this  is  an  imperative  idea. 

A  fixed  idea,  on  the  contrary,  harmonizes  with 
the  other  representations.  Therefore  it  is  never  con- 
sidered by  the  subject  as  foreign  to  the  mind  or  as  a 
pathological  phenomenon. 

A  mother  who  has  lost  her  child  is  convinced  that  if 
she  had  given  it  a  certain  kind  of  medicine  the  child 
would  not  have  died.  This  idea  does  not  leave  her, 
appears  to  her  perfectly  legitimate  and  natural :  this  is 
a  fixed  idea. 

Fixed  ideas  form  the  basis  of  certain  delusional  states, 
notably  that  of  paranoia.  They  are  also  the  starting 
point  of  a  great  many  hysterical  episodes.  In  such 
cases  they  are  often  subconscious,  that  is  to  say,  they 
exercise  their  influence  without  the  patient's  being 
conscious  of  their  existence. 

Fixed  ideas  are  not  found  exclusively  in  cases  of 
mental  alienation;  they  are  encountered  in  the  normal 
state  as  certain  tendencies  that  may  be  in  themselves 
perfectly  legitimate.  Such  are  the  desires  for  ven- 
geance, ambition,  etc. 

Autochthonous  ideas,  like  imperative  ideas,  are  de- 
veloped alongside  of  normal  associations.  The  only 
difference  is  in  the  patient's  interpretation  of  them; 


70  MANUAL  OF  PSYCHIATRY. 

while  the  imperative  idea  is  recognized  by  him  as 
pathological,  the  autochthonous  idea  is  attributed  to 
some  malevolent  influence,  most  frequently  to  some 
strange  personality.  If  he  complains,  it  is  to  the 
police  officer  and  not  to  the  physician.  A  mother 
believes  that  her  neighbor  forces  upon  her  the  idea 
of  killing  her  child:    this  is  an  autochthonous  idea. 

Closely  related  to  imperative  ideas,  autochthonous 
ideas  present  a  similar  analogy  to  hallucinations;  like 
hallucinations,  they  result  from  the  automatic  activity 
of  a  cortical  center.  But,  instead  of  playing  upon  a 
psychosensory  center,  the  morbid  irritation  occurs  in  a 
psychic  center.  Baillarger  designated  autochthonous 
ideas  by  the  term  of  psychic  hallucinations.1  This 
term  has  lately  fallen  into  disuse,  perhaps  undeservedly. 

Nothing  proves  more  conclusively  the  kinship  of  the 
two  classes  of  symptoms  than  the  frequent  transforma- 
tion of  autochthonous  ideas  into  auditory,  motor,  and 
occasionally  even  visual,  verbal  hallucinations.  The 
analogy  between  autochthonous  ideas  and  verbal  motor 
hallucinations  led  Seglas  2  to  consider  the  two  phenomena 
as  identical  in  their  nature,  the  first  being  but  a  rudi- 
mentary form  of  the  second.  This  opinion  will  appear 
somewhat  exclusive  if  we  take  into  consideration  the 
fact  that  autochthonous  ideas  may  engender  auditory 
hallucinations  3  just  as  readily  as  motor  hallucinations, 
and  that  in  many  cases  they  are  not  accompanied  by 
even  the  slightest  sensation  of  movement. 

1  Marandon  de  Montyel.  Des  hallucinations  psychiques.  Gaz. 
hebd.  de  Med.  et  de  Chirurgie,  March,  1900. 

2  Lecons  cliniques  sur  les  maladies  mentales  et  nerveuses. 

3  Wernicke.     Luc.  cit. 


SYMPTOMATOLOGY.  7 1 

Psychic  hallucinations  generally  indicate;  an  advanced 
disaggregation  of  the  personality  and  therefore  point 
to  a  grave  prognosis. 

§  4.  Disorders  of  Judgment. 

Judgment  is  the  act  by  which  the  mind  determines 
the  relationship  between  two  or  more  representations. 

When  the  relationship  is  imaginary  the  judgment 
arrives  at  a  false  conclusion.  This  becomes  a  delusion 
when  it  is  in  conflict  with  evidence. 

False  ideas  which  patients  often  entertain  concern- 
ing their  own  condition,  believing  their  health  to  be 
perfect  when  in  reality  it  is  seriously  affected,  are  to 
be  attributed  to  impaired  judgment  [lack  of  insight]. 
This  lack  of  appreciation  of  their  own  condition  is  not 
always  absolute,  and  though  in  general  it  may  be  truly 
said  that  insanity  is  a  disease  which  does  not  recog- 
nize itself,  it  must,  however,  be  acknowledged  that 
sometimes,  chiefly  at  the  onset  of  the  psychoses,  the 
patients  are  conscious  of  pathological  changes  occurring 
in  themselves.1 

Some  spontaneously  apply  to  the  physician  or  even 
request  to  be  committed.  A  sufferer  from  recurrent 
insanity,  treated  several  times  at  the  Clermont  Asylum, 
had  at  the  beginning  of  his  attacks  such  a  perfect 
realization  of  his  state  that  he  would  request  by  tele- 
gram to  have  attendants  sent  after  him. 

General  features  of  delusions. — The  ensemble  of  a 
patient's  delusions  constitute  a  delirium. 

1  Pick.  Ueber  Krankheitsbewusstsein  in  psychischen  Krankheiten. 
Arch  f.  Psychiat.,  Vol.  XIII. — Heilbronner.  Ueber  Krankheitsein- 
sicht      Allg.  Zeitsch.  f.  Psychiat.,  Vol.  LIV.  No.  4. 


72  MANUAL   OF  PSYCHIATRY. 

A  delirium  may  consist  of  purely  imaginary  ideas,  or 
it  may  be  based  upon  actual  facts  improperly  inter- 
preted. 

In  the  latter  case  we  have  delusional  interpretations. 
When  the  delusional  interpretations  involve  occurrences 
of  the  past  the  delirium  is  said  to  be  retrospective. 

Sometimes  the  delirium  follows  a  dream,  is  con- 
founded with  it,  and  presents  all  the  characteristics 
of  it  (dream  delirium);  such  is  the  case  in  many  infec- 
tious and  toxic  psychoses. 

Almost  always  the  delusions  are  multiple.  Even  in 
those  cases  which  are  sometimes  designated  by  the 
term  monomania,  the  primary  morbid  idea  entails 
a  certain  number  of  secondary  morbid  ideas  which 
result  from  it.  In  some  cases  different  delusional 
conceptions  coexist  without  there  being  any  connec- 
tion between  them,  in  others  they  are  grouped  so  as  to 
form  a  more  or  less  logical  whole  possessing  greater  or 
lesser  probability.  In  the  first  instance  the  delirium 
is  said  to  be  incoherent,  in  the  second  systematized. 

Whether  systematized  or  not,  delusions,  like  hallu- 
cinations, generally  harmonize  with  the  emotional  tone. 
This  harmony  disappears  when  the  pathological  process 
becomes  abated  in  intensity,  as  the  patient  either 
enters  upon  his  convalescence  or  lapses  into  intellectual 
enfeeblement.  In  dements  the  delusions  often  affect 
neither  the  emotions  nor  the  reactions.  A  patient  may 
claim  that  he  is  an  emperor  and  at  the  same  time  agree 
to  sweep  the  hall;  another  may  believe  himself  to  have 
lost  his  stomach  and  still  eat  with  a  hearty  appetite. 

Three  great  categories  of  delusions  are  usually  dis- 
tinguished : 


SYMPTOMATOLOGY.  73 

Melancholy  ideas; 

Ideas  of  persecution; 

Ideas  of  grandeur. 

We  shall  limit  ourselves  here  to  a  rapid  review  of 
these,  reserving  the  details  to  be  considered  in  connec- 
tion with  the  affections  in  which  the  delusions  occur. 

Melancholy  Ideas. — Very  frequent  at  the  beginning 
of  psychoses,  melancholy  ideas  may  persist  through 
the  entire  duration  of  the  disease,  as  in  affective  melan- 
cholia. 

The  principal  varieties  are: 

(A)  Ideas  of  humility  and  of  culpability.  The 
atter  are  also  called  ideas  of  self- accusation; 

(B)  Ideas  of  ruin; 

(C)  Hypochondriacal  ideas; 

(D)  Ideas  of  negation. 

A.  Ideas  of  humility  and  of  culpability. — The  patient 
considers  himself  as  a  being  good  for  nothing,  wretched, 
undeserving  of  the  attention  bestowed  upon  him,  and 
accuses  himself  of  imaginary  faults  or  crimes.  Often 
he  will  seek  out  from  his  past  life  some  insignificant 
act  to  which  he  will  attribute  extreme  gravity:  he 
stole  some  apples  when  he  was  a  boy,  or  he  forgot  to 
make  the  sign  of  the  cross  once  upon  entering  a  church. 
The  idea  of  the  crime  committed  entails  also  ideas  of 
merited  punishment:  he  expects  every  instant  to  be 
arrested,  put  to  death,  cut  to  pieces,  thrown  into  hell,  etc. 

B.  Ideas  of  ruin. — These  are  frequent  in  senile 
dements;  the  patient  believes  himself  to  be  without 
any  means,  bereft  of  everything;  his  clothes  will  be 
sold;  some  day  he  will  be  found  dead  of  starvation  on 
some  public  road. 


74  MANUAL  OF  PSYCHIATRY. 

C.  Hypochondriacal  ideas. — These  concern  the  sub- 
ject himself,  involving  either  the  physical  sphere — 
the  stomach  is  obstructed,  the  spinal  marrow  is  softened, 
the  entire  organism  is  affected  by  an  incurable  disease — 
or  the  psychic  sphere  constituting  moral  hypochon- 
driasis: the  mind  is  paralyzed,  the  intelligence  is 
destroyed,  the  will  power  is  annihilated. 

D.  Ideas  of  negation.1 — In  some  cases  these  concern 
the  subject  himself,  and  are  then  nothing  but  hypochon- 
driacal ideas  pushed  to  an  extreme:  the  brain,  the 
heart,  etc.,  are  destroyed,  the  bones  are  replaced  by 
air,  the  body  is  nothing  but  a  shadow  without  a  real 
existence.  In  other  cases  they  are  referred  to  the 
external  world:  the  sun  is  dead,  the  earth  is  nothing 
but  a  shadow,  the  universe  itself  exists  no  more  (meta- 
physical ideas  of  negation). 

By  a  singular  process,  apparently  paradoxical,  hypo- 
chondriacal ideas  and  those  of  negation  give  rise  to  ideas 
of  immortality  and  of  immensity.  The  patient  feeling 
himself,  on  account  of  the  destruction  of  his  organs, 
placed  beyond  the  laws  of  nature,  concludes  that  he 
cannot  die,  and  that  he  is  condemned  to  suffer  eternally; 
or,  dismayed  by  the  form  and  monstrous  dimensions 
of  his  body,  he  imagines  himself  obscuring  the  atmos- 
phere, filling  the  world,  etc. 

Bv  the  name  "the  svndrome  of  Cotard"  has  been 


1  Seglas.  Lemons  cliniqnes,  p.  276. — Cotard.  Du  dclire  des 
negations.  Arch,  de  neurol.,  1882. — Arnaud.  Snr  le  dclire  des 
negations.  Ann.  med.  psychol.,  Nov.-Dec.  1892. — Seglas.  Le 
dclire  des  negations.  Encycl.  des  Aide-mem. — Trenel.  Notes  sur 
les  idees  de  negation.  Arch,  de  neurol.,  March  1899. — Castin. 
Un  ras  de  dclire  hypochondria  que  a  forme  evolutive.  Ann.  m£d. 
psych.,  June  1900. 


SYMPTOMATOLOGY.  75 

designated  a  group  of  symptoms  which  is  encountered 
in  certain  cases  of  chronic  melancholic  delusional  states 
the  constituent  elements  of  which  are: 

Ideas  of  negation; 

Ideas  of  immortality  associated  with  ideas  of  damna- 
tion or  of  being  possessed;    ideas  of  immensity; 

Melancholic  anxiety; 

Tendency  to  suicide; 

Analgesia. 

The  general  features  of  melancholic  deliria  are  the 
expression  of  psychic  inhibition  and  of  the  painful 
emotional  state  which  constitute  the  basis  of  the  melan- 
cholic state. 

The  following  is  a  summary  of  the  chief  character- 
istics of  these  states,  according  to  the  admirable  study 
of  Seglas : 

a)  The  melancholic  delirium  is  monotonous;  the 
same  delusions  are  constantly  repeated,  the  inhibition 
allowing  but  little  formation  and  appearance  of  new 
ideas. 

b)  It  is  an  humble  and  passive  delirium.  The  pa- 
tient accuses  no  one  but  himself,  and  submits  without 
resistance  to  the  ill-treatment  which  he  believes  him- 
self to  be  deserving  of. 

c)  As  to  localization  in  time,  the  delusions  are 
referred  to  the  past  and  to  the  future:  the  patient 
finds  in  the  past  the  imaginary  sins  which  he  has  com- 
mitted, and  foresees  in  the  future  the  chastisements 
which  are  to  be  inflicted  upon  him.  The  persecuted 
patient,  on  the  contrary,  localizes  his  delusions  chiefly 
in  the  present.  The  persecutions  of  which  he  com- 
plains are-  actual, 


76  MANUAL   OF   PSYCHIATRY. 

d)  From  the  standpoint  of  its  development  the 
melancholic  delirium  is  centrifugal.  The  trouble  begins 
with  the  subject  himself  and  extends  gradually  to  his 
friends,  to  his  country,  and  to  the  entire  universe,  who 
suffer  through  his  faults. 

e)  The  melancholic  delirium  is  secondary,  that  is 
to  say,  it  is  the  consequence  of  the  sadness  and  of  the 
moral  pain.  It  shares  this  characteristic  with  most  of 
the  other  delusional  states  which  are  generally  but 
the  expression  of  the  emotional  tone  of  the  subject.1 

Melancholic  delirium  may  have  two  grave  conse- 
quences which  I  shall  have  a  great  deal  of  occasion  to 
emphasize:   suicide  and  refusal  of  food. 

Ideas  of  persecution. — Like  melancholy  ideas,  ideas 
of  persecution  are  of  a  painful  character.  But  while 
the  melancholiac  considers  himself  a  culpable  victim 
and  submits  beforehand  to  the  chastisements  which  he 
believes  he  has  merited,  the  subject  of  persecution  is 
convinced  of  his  innocence  and  protests  and  defends 
himself. 

.  Ideas  of  persecution  may  be  divided  into  two  groups, 
according  to  whether  they  are  or  are  not  accompanied 
by  hallucinations. 

In  the  first  group  they  are  associated  with  halluci- 
nations, generally  of  an  unpleasant  character,  among 
which  auditory  verbal  hallucinations  and  hallucinations 
of  general  sensibility  are  most  prominent.  After  a 
certain  time  the  phenomena  of  psychic  disaggregation 
supervene:  motor  hallucinations,  autochthonous  ideas, 
reduplication  of  the  personality,  etc. 


1  S6glas.     Logons  cliniques. 


SYMPTOMATOLOGY.  77 

In  the  second  group  the  ideas  of  persecution  are 
peculiarly  associated  with  faulty  interpretations;  any 
chance  occurrence  is  ascribed  by  the  patient  to  malevo- 
lence; he  sees  in  everything  evidences  of  hostility 
against  him,  and  attributes  to  the  most  ordinary  and 
unimportant  facts  and  actions  a  significance  which  is 
as  grave  as  it  is  fanciful.  This  form  of  ideas  of  perse- 
cution is  frequent  at  the  onset  of  certain  psychoses; 
it  also  constitutes  the  basis  of  an  affection  known  as 
paranoia  or  reasoning  insanity. 

Some  patients  do  not  know  their  persecutors.  Others 
accuse  some  particular  persons  or  societies  (Jesuits, 
Freemasons).  Still  others  bear  their  hatred  towards 
some  certain  individual  who  is,  in  their  eyes,  the  instiga- 
tor of  all  the  injurious  procedures  of  which  they  are  the 
victims,  "the  great  master  of  the  persecutions/'  as 
one  such  patient  once  said. 

Of  all  delusions  those  of  persecution  are  the  most 
irreducible  and  are  entertained  by  the  patients  with 
the  most  absolute  conviction.  Almost  always  the 
patients  resent  to  have  them  disputed.  In  themselves 
these  delusions  do  not  have  an  invariable  influence 
upon  the  prognosis,  excepting  that,  in  a  very  general  way, 
they  are  of  more  serious  import  than  melancholy  ideas. 

Of  all  delusions  these  also  present  the  greatest  tendency 
to  systematization  and  to  progressive  evolution.  A  per- 
fectly systematized  persecutory  delirium  should  comprize : 

(a)  A  precise  idea  of  the  nature  of  the  persecutions; 

(b)  An  exact  knowledge  of  the  persecutors,  of  their 
aim,  and  of  the  means  employed  by  them; 

(c)  A  plan  of  defense  in  harmony  with  the  nature  of 
the  delusions. 


78  MANUAL  OF  PSYCHIATRY. 

In  the  examination  of  cases  of  persecutory  delirium 
one  should  always  attempt  to  determine  these  points, 
on  account  of  their  great  practical  importance. 

Ideas  of  grandeur. — Ideas  of  grandeur  chiefly  appear 
in  demented  states  and  are  often  of  a  particularly 
absurd  nature,  bearing  the  stamp  of  intellectual  en- 
feeblement.  The  patients  are  immensely  rich,  all- 
powerful;  they  are  popes,  emperors,  creators  of  the 
universe.  Generally  they  naively  declare  these  pom- 
pous titles  without  being  at  all  concerned  by  the  fla- 
grant contradiction  existing  between  their  actual  state 
and  their  ostensible  almightiness.  A  general  paretic 
was  once  asked:  "If  you  are  God,  how,  then,  does  it 
happen  that  you  are  locked  up?'7  " Because  the  doctor 
refuses  to  let  me  go/'  he  replied  simply.  It  is  not 
rare  to  see  a  pseudo-pope  obey  without  a  murmur 
the  orders  of  hospital  attendants  and  assist  with  the 
best  possible  grace  in  the  most  menial  labor. 

Often  the  patient's  costume  is  in  harmony  with  the 
title:  uniforms  of  the  oddest  fancy,  multicolored  tin- 
sels, numerous  decorations,  etc. 

When  the '  intellectual  enfeeblement  is  less  pro- 
nounced, as,  for  instance,  in  certain  cases  of  dementia 
precox,  the  subject  shows  more  logic  in  his  conduct. 
He  assumes  an  air  of  dignity,  avoids  all  association 
with  the  other  patients,  and  declines  with  a  contemptu- 
ous smile  all  suggestions  of  employment. 

Ideas  of  grandeur  are  also  met  with  in  certain  acute 
psychoses,  as  in  mania,  for  instance,  and  in  certain 
forms  of  systematized  deliria  without  intellectual 
enfeeblement  ("  Paranoia  originaire"  of  Sander). 


CHAPTER  IV. 
SYMPTOMATOLOGY  (Continued). 

AFFECTIVITY —REACTIONS.— CCENESTHESI A— NOTION 
OF  PERSONALITY. 

§  1.  Disorders  of  Affectivity. 

Pathological  modifications  of  affectivity  are  en- 
countered in  the  course  of  all  psychoses.  They  always 
appear  early,  and  often  before  any  of  the  other  symp- 
toms. 

The  principal  ones  are: 

(a)  Diminution  of  affectivity:    morbid  indifference; 

(6)  Exaggeration  of  affectivity; 

(c)  Morbid  depression; 

(d)  Morbid  anger; 

(e)  Morbid  joy. 

Diminution  of  affectivity. — In  its  most  pronounced 
degree  indifference  involves  all  the  emotions,  as  in 
extreme  states  of  dementia  (general  paresis  and  senile 
dementia  in  their  terminal  stages),  in  which  it  is  associa- 
ted with  general  intellectual  enfeeblement.  In  its  less 
severe  forms  the  indifference  is  manifested  by  disap- 
pearance of  the  most  elevated  and  the  most  complex 
sentiments,  with  conservation  and  often  even  exalta- 

79 


80  MANUAL   OF  PSYCHIATRY. 

tion  of  the  sentiments  of  an  inferior  order.  The  altru- 
istic tendencies  are  the  first  to  become  effaced,  while 
the  egoistic  sentiments  persist.  Only  the  satisfaction 
of  their  material  wants  still  concerns  the  patients  and 
governs  their  activity.  Many  take  no  interest  during 
the  visits  of  relatives  in  anything  excepting  the  eatables 
brought  to  them;  they  eat  as  much  as  they  can,  fill 
their  pockets  with  the  rest,  and  leave  without  taking 
the  trouble  to  express  their  thanks  or  even  to  bid  their 
visitors  good-by. 

The  morbid  indifference  may  be  conscious  or  uncon- 
scious. In  the  first  case  it  is  realized  by  the  subject 
as  a  painful  phenomenon.  The  patients  often  say:  "I 
have  lost  all  feeling,  nothing  excites  me,  nothing  pleases 
me,  nothing  makes  me  sad."  Some  complain  of  being 
unable  to  suffer.  This  state,  which  may  be  called 
painful  psychic  anaesthesia,  is  frequent  at  the  beginning 
of  psychoses  and  sometimes  persists  through  the  entire 
duration  of  the  affection  (affective  melancholia,  de- 
pressed periods  of  recurrent  insanity). 

In  the  second  case,  which  is  more  frequent,  the  dimi- 
nution of  affectivity  is  not  noticed  by  the  patient. 
Such  is  always  the  case  in  states  of  dementia. 

The  alteration  of  the  other  mental  faculties,  such  as 
memory  and  general  intelligence,  are  not  necessarily 
proportionate  to  those  of  the  affectivity.  Notably, 
in  dementia  praecox  it  is  not  rare  to  find  a  fairly  good 
memory  and  a  relatively  lucid  intelligence  coexisting 
with  complete  indifference. 

Exaggeration  of  affectivity. — Often  combined  with 
indifference,  as  has  been  shown  above,  exaggeration 
of  affectivity  is  encountered  in  most  mental  affections, 


SYMPTOMATOLOGY.  81 

congenital  and  acquired.  It  constitutes  the  basis  of 
irritable  and  changeable  moods  and  of  the  extreme 
irascibility  so  often  seen  among  the  insane  and  among 
degenerates  in  general. 

In  the  acquired  psychoses  it  is  an  early  symptom, 
appearing  at  times  long  before  the  other  phenomena. 
An  individual  previously  calm,  gentle,  kind,  becomes 
disagreeable,  ill-natured,  violent.  "He  is  completely 
changed/'  is  often  remarked  by  the  relatives. 

Irritability  is  almost  always  associated  with  vari- 
ability of  moods. 

Disorders  of  affectivity  serve  to  characterize  a  large 
and  important  group  of  patients  included  under  the 
somewhat  vague  designation  of  "  constitutional  psy- 
chopaths." In  these  individuals  the  emotions  are 
entirely  out  of  proportion  with  their  causes.  The 
death  of  an  animal  plunges  them  into  unlimited  despair, 
the  sight  of  blood  brings  on  syncope,  the  most  simple 
affairs  preoccupy  their  minds  so  as  to  make  them 
lose  their  sleep.  Sensitive  in  the  highest  degree,  they 
see  in  everything  malevolent  intentions,  disguised 
reproaches.  But  their  sentiments,  though  very  intense, 
are  of  short  duration;  sorrows,  enthusiasms,  resent- 
ments are  with  them  but  a  short  blaze. 

Morbid  depression.  —  Depression  presents  itself  in 
pathological  states,  as  it  does  in  the  normal  state  under 
two  forms:  active  and  passive.  This  distinction  is 
founded  upon  the  presence  or  absence,  or  rather  upon 
the  intensity,  of  the  moral  pain.  While  in  active  de- 
pression the  moral  pain  is  very  prominent,  in  passive 
depression  it  is  dull,  vague,  scarcely  appreciable.  In- 
deed, as  Dumas  says,  ' c  the  element  of  pain  is  not  absent 


82  MANUAL  OF  PSYCHIATRY. 

in  passive  melancholia;   but  it  is  not  an  acute  and  dis- 
tinct moral  pain.     It  is  but  vaguely  perceived."  1 

Passive  depression. — The  fundamental  features  of  pas- 
sive depression  are  lassitude,  discouragement,  resigna- 
tion. It  is  always  associated  with  a  marked  degree  of 
psychic  inhibition,  aboulia,  and  moral  anaesthesia,  and 
may  be  complicated  by  delusions  and  hallucinations. 
It  is  accompanied  by  organic  changes  which  have 
been  extensively  studied  by  physiologists  (Darwin, 
Claude  Bernard,  Lange),  and  to  which  Dumas  has  de- 
voted one  of  the  most  interesting  chapters  in  his  book, 
"La  tristesse  et  la  joie." 

Depression  is  always  associated  with  a  state  of  per- 
ipheral and  probably  cerebral  vaso-constriction,  in  which 
Lange  believed  he  had  found  the  immediate  cause  of  this 
emotion.  This  vaso-constriction  is  very  evident  in  the 
pallor  of  the  skin,  coldness  of  the  extremities,  and  ab- 
sence of  the  peripheral  pulse,  which  are  constant  fea- 
tures of  the  depression  of  melancholia.-  The  opinion  of 
Lange  is,  however,  too  exclusive.  "This  vaso-con- 
striction, which  in  the  peripheral  organs  results  in 
coldness  and  pallor  of  the  tissues,  brings  about  in  the 
brain  a  condition  of  anaemia,  undoubtedly  contributing 
to  the  maintenance  of  the  mental  and  motor  inertia; 
but  it  cannot  be  asserted  with  certainty  that  it  is  the 
only  cause  of  these  phenomena.  Morselli  and  Bordoni- 
Uffreduzzi  have  shown  long  since,  in  fact,  that  the 
phenomena  of  depressed  intellectual  activity  may  ap- 
pear before  the  cerebral  circulatory  changes;  this  leads 
to  the  conclusion  that  depression  begins  with  being  the 

1  La  tristesse  et  la  joie,  p.  29.     Paris,  F.  Alcan. 


SYMPTOMATOLOGY.  83 

cause  of  the  circulatory  changes  before  becoming  sub- 
ject to  their  influence."  x 

In  the  very  rare  cases  in  which,  in  spite  of  the  periph- 
eral vaso-constriction,  the  cardiac  impulse  retains  its 
force,  the  blood  pressure,  according  to  the  laws  formu- 
lated by  Marey,  rises;  this  condition  constitutes  the 
first  type  of  depression,  depression  with  hypertension. 

But  almost  always  the  heart  participates  in  the  gen- 
eral atony  which  the  depression  gives  rise  to,  so  that  the 
blood  pressure  falls  in  spite  of  the  peripheral  vasocon- 
striction: this  constitutes  the  second  type  of  depres- 
sion, depression  with  hypotension  (Dumas). 

The  respiratory  disorders  are  no  less  constant  than  the 
circulatory  ones.  The  respirations  are  shallow,  irregu- 
lar, interrupted  by  deep  sighing.  The  quantity  of  car- 
bon dioxide  excreted  tends  to  diminish . 

The  general  nutrition  is  impaired;  this  results  in  loss 
of  flesh,  which  is  but  slight  if  the  depression  lasts  no 
longer  than  a  few  days,  and  which  persists  as  long  as 
the  affective  phenomenon  itself.  The  weight  does  not 
return  to  the  normal  until  the  depression  disappears, 
i.e.,  until  the  patient  either  recovers  or  becomes  de- 
mented. 

The  appetite  is  diminished  the  tongue  is  coated,  the 
breath  is  offensive.  The  process  of  digestion  is  accom- 
panied by  uneasiness  and  often  by  pain  in  the  epigas- 
trium.    Finally,  there  is  almost  always  constipation. 

The  sluggish  metabolism  shown  by  the  diminished 
elimination  of  carbon  dioxide  is  also  apparent  from  the 
quantitative   and   qualitative   changes   in   the   urinary 

Furnas,     hoc.  cit.,  p.  239. 


b4  MANUAL  OF  PSYCHIATRY. 

excretion.  The  quantity  of  urine  voided  in  twenty- 
four  hours  is  diminished.  The  quantity  of  urea,  as  well 
as  that  of  phosphoric  acid,  is  also  diminished  (Observa- 
tions of  Dumas  and  Serveaux). 

The  toxicity  of  the  urine  in  depression  is  undoubtedly 
of  interest,  but  the  results  so  far  obtained  are  somewhat 
conflicting.  According  to  some  authors  it  is  increased, 
according  to  others,  diminished.  This  subject,  still  in 
a  state  of  confusion,  should  be  excluded  from  the  domain 
of  practical  psychiatry. 

Active  depression. — The  special  feature  of  active  de- 
pression is  the  moral  pain,  which  is  distinct  and  suffi- 
ciently intense  to  render  the  subject  subjectively  con- 
scious of  it.  The  appearance  of  this  new  phenomenon 
modifies  to  a  certain  extent  the  fundamental  symptoms 
which  have  been  described  in  connection  with  passive 
depression. 

Like  physical  pain,  moral  pain  tends  to  limit  the 
field  of  consciousness,  to  exclude  other  intellectual 
manifestations,  and  to  become  what  Schiile  has  desig- 
nated by  the  term  pain-idea.  In  certain  cases  the 
disturbance  of  consciousness  which  it  causes  results 
in  marked  disorientation  and  confusion.  These  phe- 
nomena, caused  by  the  pain,  become  less  marked  as  the 
pain  becomes  abated  in  intensity  and  disappear  as  the 
paroxysm  passes  off. 

When  moral  pain  attains  a  certain  intensity,  it  results 
in  anxiety.  This  phenomenon  consists  chiefly  hi  a 
feeling  of  oppression  or  constriction,  most  frequently 
localized  in  the  precordial  region,  occasionally  in  the 
epigastrium  or  in  the  throat,  and  more  rarely  in  the 
head.     This  peculiar  feeling  is  always  accompanied  by 


SYMPTOMATOLOGY.  85 

certain  somatic  phenomena,  the  most  important  of 
which  are  pallor  of  the  skin,  sometimes  actual  cyano- 
sis, panting  respiration,  general  tremor,  irregular  and 
accelerated  pulse,  and  dilatation  of  the  pupils,  which  is 
often  very  marked. 

Anxiety  is  frequently  seen  in  depressed  states.  It 
also  occurs  in  obsessions.  It  may  appear  without  cause 
in  certain  psychopaths  (the  paroxysmal  anxiety  of 
Brissaud). 

From  the  standpoint  of  the  reactions,  moral  pain,  like 
physical  pain,  may  manifest  itself  either  by  a  sort  of 
psychomotor  paralysis, — so  that  the  patient  remains 
immovable,  with  a  haggard  expression,  silenced,  so 
to  speak,  by  the  anxiety, — or  by  various  phenomena 
of  agitation. 

In  the  latter  case,  the  more  frequent,  the  pain,  an 
active  phenomenon,  brings  about  a  reaction  which  to  a 
certain  extent  overcomes  the  fundamental  psychic  in- 
hibition and  manifests  itself  by  two  symptoms  which  are 
frequently  seen  together,  motor  activity  and  delusions. 

Acting  as  a  stimulus,  moral  pain  overcomes  the  motor 
inertia  of  melancholia  and  gives  rise  to  melancholic 
agitation,  which  is  characterized  by  movements  that 
are,  in  the  normal  state,  the  expression  of  violent 
despair.  The  patient  wrings  his  hands,  strikes  his 
head  against  the  wall,  etc.  The  agitation  of  anxiety 
is  essentially  an  expression  of  opposition,  of  resistance. 
The  reactions  are  either  automatic  or  governed  by  the 
delusions:  movements  of  flight,  refusal  of  food,  attempts 
at  suicide,  etc. 

Suicide  is  one  of  the  most  formidable  consequences  of 
moral  pain.     Though  most  melancholiacs  have  a  desire 


86  MANUAL   OF   PSYCHIATRY. 

to  die,  the  aboulia  which  characterizes  the  state  of 
depression  very  seldom  permits  them  to  carry  out  their 
desire.  On  recovering  part  of  their  energy  they  are 
apt  to  make  suicidal  attempts. 

Delusions  are  a  frequent  but  not  a  constant  manifesta- 
tion of  moral  pain.  They  are  absent  in  certain  melan- 
cholias in  spite  of  the  existence  of  even  very  painful 
depression. 

What  is  the  mechanism  of  the  production  of  delusions 
in  melancholia?  The  most  widely  accepted  opinion  is 
that  of  Griesinger:  l  "The  patient  feels  that  he  is  a 
prey  to  sadness ;  but  he  is  usually  not  sad  except  under 
the  influence  of  depressing  causes;  moreover,  accord- 
ing to  the  general  law  of  cause  and  effect,  this  sadness 
must  have  a  ground,  a  cause, — and  before  he  asks  him- 
self this  question,  he  already  has  an  answer;  all  kinds 
of  mournful  thoughts  occur  to  him  as  explanations, 
dark  presentiments,  apprehensions,  over  which  he 
broods  and  ponders  until  some  of  these  ideas  become  so 
dominating  and  so  persistent  as  to  fix  themselves  in  his 
mind,  at  least  for  some  time.  For  this  reason  these 
delusions  have  the  character  of  attempts  on  the  part  of 
the  patient  to  explain  to  himself  his  own  state." 

Though  of  great  interest,  this  ingenious  theory  is 
perhaps  somewhat  too  exclusive.  Kraepelin  remarked, 
in  fact,  that  the  delusions  occurring  in  states  of  de- 
pression do  not  always  present  the  character  of  expla- 
nations sought  by  the  patient.  Many  melancholiacs 
instead   of    accepting  the   delusions,   on  the  contrary 


1  Griesinger.     Pathologie   und    Therapie   der  psychischen  Krank- 
heiten. 


SYMPTOMATOLOGY.  87 

reject  them,  at  least  in  the  beginning.  Again,  the 
appearance  of  a  delusion  does  not  bring  with  it  the  rela- 
tive calm  which  would  be  expected  if  it  would  really 
constitute  the  explanation  sought  by  the  patient.  It 
seems,  then,  that  this  interpretation,  ingenious  though  it 
is,  is  rather  superficial.  The  view  of  Dumas  appears  to 
be  nearer  the  truth.  The  moral  pain  provokes  delusions 
because  it  acts  as  a  stimulus,  struggling  against  the 
lassitude,  and  finally  conquering  it.  Thus  there  is  no 
logical  relationship  between  the  moral  pain  and  the 
delusions,  but  rather  a  dynamic  one. 

Morbid  anger. — Pain,  associated  with  a  representation 
of  its  cause,  and  sufficiently  intense  to  overcome  the 
psychic  paralysis  which  is  an  essential  accompaniment 
of  depression,  results  in  anger. 

The  violent  and  disordered  reactions  displayed  in 
anger  have  a  purely  automatic  origin,  and  are  often 
associated  with  a  disturbance  of  consciousness  and  of 
perception  which  finds  various  expressions  in  popular 
language;  a  man  who  is  a  victim  of  violent  anger  is 
often  said  to  be  "beside  himself/'  he  " forgets  himself." 

Tike  all  emotions,  anger  is  accompanied  by  somatic 
changes.  The  principal  ones  are:  an  increase  of 
cardiac  activity  and  an  elevation  of  arterial  tension*, 
peripheral  vaso-dilatation,  chiefly  noticeable  in  the 
face  which  assumes  a  congested  appearance;  jerky 
and  convulsive  respiratory  movements;  an  increase 
of  most  of  the  secretions:  abundant  salivation  (foam- 
ing), more  or  less  jaundice,  diarrhoea,  polyuria;  some- 
times a  suspension  of  the  milk  secretion;  an  arrest  of 
the  menstrual  flow;  more  or  less  marked  cutaneous 
ansethesia;    general  tremor. 


88  MANUAL  OF  PSYCHIATRY. 

Anger  may  be  met  with  in  all  the  psychoses,  except- 
ing perhaps  affective  melancholia.  It  sometimes 
reaches  the  intensity  of  furor,  notably  in  idiots,  epilep- 
tics, and  other  patients  with  profound  disorders  of 
consciousness.  It  is  always  associated  with  morbid 
irritability  and  impulsiveness,  of  which  it  is  but  an 
expression. 

Morbid  joy  or  morbid  euphoria. — This  presents  itself 
"in  two  forms:  one,  a  calm  joy,  analogous  to  passive 
depression;  the  other,  an  active,  exuberant  joy,  analo- 
gous to  active  depression. 

The  first  when  of  average  intensity  manifests  itself 
by  a  state  of  satisfaction,  a  vague  sense  of  well-being. 
It  is  encountered  in  general  paresis  and  in  certain  forms 
of  tuberculosis.  The  optimism  and  astonishing  con- 
tentment of  some  consumptives  who  have  reached 
the  last  stage  of  their  illness  are  well-known  phe- 
nomena. 

When  calm  euphoria  reaches  its  highest  development 
it  becomes  ecstasy,  in  which  it  is  not  accompanied  by 
any  motor  reaction.  Such  is  the  case  in  certain  forms 
of  mystic  deliria. 

Much  more  frequent  than  this  calm  and  tranquil 
form  of  euphoria,  the  active  form,  noisy,  accompanied 
by  motor  reactions,  is  a  constant  symptom  of  the  so- 
called  expansive  forms  of  psychoses:  general  paresis 
with   excitement,    mania,    certain   toxic   deliria. 

Unlike  depression,  euphoria  permits  of  an  easy  asso- 
ciation of  ideas  and  quick  motor  reactions.  These 
two  phenomena  do  not  always  indicate  real  psychic 
activity.  In  fact  most  frequently  in  pathologic  euphoria 
the  associations  formed  are  aimless,  independent  of  all 


SYMPTOMATOLOGY.  89 

voluntary  intellectual  activity,  and  the  motor  reactions 
bear  the  stamp  of  impulsive  acts  originating  automat- 
ically. 

When  pushed  to  a  certain  degree,  the  apparent 
rapidity  of  the  associations  develops  into  flight  of 
ideas  mentioned  previously.1 

The  aspect  of  the  patient  in  euphoria  is  the  direct 
opposite  of  that  in  depression.  The  expression  is 
bright,  smiling,  with  the  head  raised  and  the  body 
upright.  The  speech  is  very  animated  and  accom- 
panied by  numerous  gestures. 

The  concomitant  physical  phenomena  are  in  general 
those  of  joy,  that  is  to  say,  the  reverse  of  those  of 
depression. 

First  come  the  cardio-vascular  and  respiratory  phe- 
nomena: peripheral  (and  probably  cerebral)  vasodila- 
tation, acceleration  of  the  pulse,  increased  force  of 
the  cardiac  impulse,  and  an  elevation  or  a  lowering 
of  the  blood  pressure,  depending  upon  whether  the 
increased  heart  action  does  or  does  not  compensate 
for  the  peripheral  vaso-dilatation. 

The  respirations  are  accelerated,  deep  and  regular; 
the  elimination  of  carbon  dioxide  is  increased.  The 
general  nutrition  is  active,  as  is  seen  from  the  patient's 
gain  in  flesh  and  from  the  increase  of  excrementitious 
products  in  the  urine. 

These  different  phenomena,  constant  in  normal  joy 
and  frequent  in  morbid  euphoria,  are  however  absent 
in  some  cases,  when  other  factors  are  present  which 
counterbalance  the  favorable  influence  of  joy.  Such 
is  the  case  when  there  is  intense  motor  agitation,  which, 

1  See  pp.  66  and  67. 


90  MANUAL  OF  PSYCHIATRY. 

in  spite  of  the  euphoria,  causes  a  rapid  loss  of  flesh. 
Such  is  the  case  also  when  the  underlying  condition 
is  some  severe  bodily  affection.  The  general  paretic 
or  the  consumptive  with  euphoria  is  none  the  less 
cachectic,  for  in  such  cases  a  generally  flourishing  state 
of  health  is  not  possible. 

Certain  anomalies  are  very  difficult  to  explain.  Some 
maniacs  show,  instead  of  an  acceleration  of  the  pulse 
characteristic  of  states  of  euphoria,  a  slowing  which 
is  at  times  quite  marked.  I  have  observed  in  a  young 
maniacal  girl  with  marked  excitement  less  than  forty- 
five  pulsations  per  minute  for  several  days.  This  phe- 
nomenon has,  I  think,  not  as  yet  been  satisfactorily 
explained. 

§  2.  Disorders  of  the  Reactions. 

The  different  psychic  operations  which  we  have  so 
far  considered, — perception,  associations  of  ideas,  affec- 
tive phenomena, — find  their  outward  expression  in  the 
reactions.  Like  associations  of  ideas,  reactions  may 
be  of  two  kinds:   voluntary  and  automatic. 

Between  a  voluntary  act  accomplished  in  full  self- 
possession  and  a  purely  automatic  act  there  are  all 
intermediate  gradations;  we  pass  from  the  one  to  the 
other  by  a  gradual  insensible  transition.  The  partici- 
pation of  the  conscious  will  diminishes  as  that  of  the 
automatism  becomes  more  prominent,  or  inversely. 

We  have  seen  that  in  normal  ideation  voluntary  and 
conscious  associations  tend  to  inhibit  the  automatic 
associations.  Similarly  the  conscious  will  tends  to 
inhibit  the  automatic  reactions. 


SYMPTOMATOLOGY.  91 

We  shall  study:  (1)  dboulia,  or  paralysis  of  voluntary 
reactions;   and  (2)  automatic  reactions. 

Aboulia. — Complete  paralysis  of  the  will  brings  about, 
depending  upon  the  character  of  the  case,  either  stupor 
or  absolute  automatism.  When  less  pronounced  it  is 
manifested  clinically  by  a  general  sense  of  fatigue  and 
discouragement,  by  slowness  and  unsteadiness  of  the 
movements,  and  by  the  painful  effort  that  is  necessary 
for  the  accomplishment  of  all  spontaneous  or  com- 
manded acts.  The  voluntary  apparatus  then  resembles 
a  rusty  mechanism  which  works  only  with  difficulty. 

Like  sluggishness  of  the  associations  of  ideas,  which 
is  in  most  cases  associated  with  it,  aboulia  is  a  mani- 
festation of  psychic  paralysis. 

Automatic  reactions. — These  may  be  paralyzed  to 
the  same  degree  as  the  voluntary  reactions  and  give 
place  to  the  absolute  inertia  of  stupor;  or,  on  the  con- 
trary, they  may  become  exalted  by  reason  of  the 
enfeeblement  of  the  conscious  will. 

We  distinguish:  (A)  positive  automatic  reactions; 
and  (B)  negative  automatic  reactions. 

(A)  Positive  automatic  reactions  are  expressed  clinic- 
ally by  two  phenomena:  suggestibility  and  impulsive- 
ness. 

By  suggestibility  is  understood  a  state  in  which  the 
reactions  are  compelled  by  external  impressions.  Its 
most  perfect  expression  is  catalepsy,  in  which  the  limbs 
assume  and  retain  the  attitudes  in  which  they  are 
placed  by  the  examiner.  This  phenomenon  has  been 
termed  waxy  flexibility  (flexibilitas  cerea). 

Many  patients  appear  to  have  lost  all  individual  will 
and  are  reduced  to  pure  automatons.      Some    repeat 


92  MANUAL  OF  PSYCHIATRY. 

exactly  the  words  (echolalia)  or  the  gestures  (echo- 
praxia)  of  the  persons  around  them.  Others  exhibit  no 
spontaneous  activity,  but  are  able  to  execute  without 
hesitation  any  command.  Such  is  the  case  with  hyp- 
notized subjects,  certain  catatonics,  etc.  Sometimes 
it  suffices  to  start  them  moving,  when  they  will  con- 
tinue and  accomplish  a  series  of  acts  to  which  they  are 
accustomed. 

Suggestibility  is  the  dominant  note  of  the  character  of 
certain  individuals,  mostly  credulous  and  weak-minded, 
whose  thoughts  are  governed  by  external  impressions, 
whose  will  is  nil,  and  whq  yield  to  the  domination  of  the 
most  diverse  influences,  good  or  bad.  Many  criminals 
belong  to  this  class. 

Impulsive  reactions  or  impulses  are  to  be  divided  into 
three  groups:  (a)  the  passionate  impulses;  (b)  the 
simple  impulses;   (c)  the  phenomena  of  stereotypy. 

(a)  The  passionate  impulses  always  depend  upon  an 
abnormal  irritability.  They  are  determined  by  causes 
that  are  often  insignificant  and  are  accomplished 
independently  of  any  mental  reflection.  They  are 
met  with  in  a  great  many  patients:  constitutional 
psychopaths,  epileptics,  maniacs,  etc.  A  maniac  feels 
his  neighbor  give  him  a  slight  push;  he  immediately 
strikes  him  without  reflecting  that  the  latter  had  no 
malevolent  intention,  that  he  was  perhaps  even  uncon- 
scious of  having  touched  him,  etc.  This  is  a  passionate 
automatic  reaction. 

(b)  The  simple  impulses,  purely  automatic,  appear 
without  any  emotional  shock  and  without  a  shadow 
of  provocation.  One  patient  suddenly  threw  into  the 
fire  the  gloves,  hat,  and  handkerchief  of  her  daughter 


SYMPTOMATOLOGY.  93 

who  came  to  visit  her  at  a  sanitarium.  Afterwards 
during  a  moment  of  remission  she  remembered  per- 
fectly the  act  and  the  circumstances  under  which  it 
was  accomplished,  but  was  not  able  to  furnish  any 
explanation  at  all  for  it. 

The  impulse  may  be  conscious.  A  patient  is  sud- 
denly seized  with  a  strong  desire  to  steal  some  object 
from  a  show-window,  the  possession  of  which  could  be 
neither  useful  nor  pleasant  to  him;  he  does  not  yield 
to  this  impulse,  which  he  recognizes  as  pathological. 
This  is  a  conscious  impulse.  This  phenomenon  is 
closely  allied  to  imperative  ideas,  of  which  it  is  but 
an  accentuation. 

(c)  Stereotypy  consists  in  a  morbid  tendency  to 
retain  the  same  attitudes,  or  to  repeat  the  same  words 
or  the  same  movements.  Hence  the  three  kinds  of 
stereotypy : 

Stereotypy  of  attitudes; 

Stereotypy  of  movements; 

Stereotypy  of  language:  verbigeration. 

Certain  patients  remain  for  hours  at  a  time  in  the 
most  uncomfortable  attitudes;  others  will  walk  a  long 
distance,  taking  alternately  three  steps  forward  and 
two  backward;  still  others  will  repeat  indefinitely  the 
same  phrase  or  the  same  verse. 

(B)  Negative  automatism. — This  forms  the  basis  of 
negativism  and  consists  in  the  annulment  of  a  ato1uq- 
tary  normal  reaction  by  a  pathological  antagonistic  ten- 
dency. 

The  patient  is  requested  to  give  his  hand;  the  volun- 
tary reaction,  which  tends  to  appear  and  which  would 
result  in  the  execution  of  the  command,  is  arrested,  sup- 


94  MANUAL  OF  PSYCHIATRY. 

pressed  by  automatic  antagonism.  This  disorder  of  the 
will  has  been  designated  by  Kraepelin,  who  has  made 
an  admirable  study  of  it,  by  the  term  "Sperrung, "  a 
word  which,  literally  translated  into  English,  means 
blocking.  A  more  significant  term  perhaps  would  be 
psychic  interference.  The  two  antagonistic  tendencies 
neutralize  each  other  like  waves  of  opposite  directions 
in  physics. 

On  a  superficial  examination  negativism  may  resem- 
ble aboulia.  These  are,  however,  two  very  different 
phenomena.  While  the  latter,  purely  passive,  is  the 
result  of  a  persistent  paralysis  against  which  the  patient 
struggles  with  more  or  less  success,  the  former,  an  active 
phenomenon,  depends  not  upon  a  parafysis  but  upon  a 
perversion  of  the  will.  Negativism  is  often  manifested 
only  in  certain  kinds  of  reactions.  One  patient  who 
walks  about  without  any  effort  does  not  open  his  mouth. 
Another  who  makes  his  toilet,  eats  unassisted,  and  even 
works,  remains  in  complete  mutism,  making  no  response 
in  spite  of  all  perseverance  on  the  part  of  the  questioner. 

In  a  more  marked  degree  negative  automatism  results 
not  only  in  the  arrest  of  normal  reactions,  but  also  in 
the  production  of  contrary  reactions. 

Thus  if  one  attempts  to  flex  the  patient's  head  he 
extends  it,  and  vice  versa.  If  he  is  reo^ested  to  open 
his  half-shut  eyes  he  closes  them,  and  if  the  examiner 
attempts  to  force  them  open,  his  orbicularis  muscle  con- 
tracts in  a  veritable  spasm.  Wernicke  observed  that 
while  flexibilitas  cerea  chiefly  shows  itself  in  the  limbs, 
negativism  mostly  affects  the  muscle  groups  of  the  head 
and  neck. 


SYMPTOMATOLOGY.  95 


§  3.  Disorders   of   Ccenesthesia   and   of  the 
Personality. 

Disorders  of  coenesthesia. —  By  coenesthesia  or  vital 
sense  is  understood  "the  general  feeling  which  results 
from  the  state  of  the  entire  organism,  from  the  normal 
or  abnormal  progress  of  the  vital  functions,  par- 
ticuarly  of  the  vegetative  functions  "  (Hoffding.)  The 
stimuli  which  produce  this  sense  are  vague  and  poorly 
localized,  and  are  perceived  not  individually  but  together 
as  a  whole. 

The  harmony  which  normally  exists  between  the  di- 
verse organic  functions  produces  a  vague  sense  of  satis- 
faction and  of  well-being.  All  causes  tending  to  destroy 
this  harmony  will  produce  in  the  consciousness  a  feeling 
of  malaise  and  of  suffering  more  or  less  definite  and  more 
or  less  acute.  Thus  the  disorders  of  coenesthesia  are 
intimately  connected  with  disorders  of  affectivity;  most 
of  the  depressed  states  have  for  their  basis  an  alteration 
of  the  vital  sense. 

Disorders  of  the  personality. — Alterations  in  the  per- 
sonality constitute  the  symptom  which,  following  Wer- 
nicke, we  have  termed  autopsychic  disorientation. 

These  disorders  may  be  arranged  in  three  principal 
groups : 

(a)  Weakening  of  the  notion  of  personality; 

(b)  Transformation  of  the  personality; 

(c)  Reduplication  of  the  personality. 

(a)  The  notion  of  personality  may  be  incomplete  or 
absent;  it  may  have  never  been  developed  at  all,  or  it 
may  have  been  but  incompletely  developed,  as  in  idiots 


96  MANUAL   OF  PSYCHIATRY. 

and  imbeciles,  or  it  may  have  disappeared  or  have  be- 
come weakened  under  the  influence  of  a  pathogenic 
cause,  as  in  mental  confusion,  epileptic  delirium,  melan- 
cholic depression  with  stupor,  etc. 

(b)  Transformation  of  the  personality  may  be  complete 
or  incomplete. 

In  the  first  case  the  patients  forget  or  deny  everything 
pertaining  to  their  former  personality.  Thus  one  patient 
claimed  that  she  was  Mary  Stuart,  wanted  to  be  ad- 
dressed as  "Her  Majesty  the  Queen  of  Scotland,"  and 
attired  herself  in  costumes  similar  to  those  of  that  time. 
She  became  furious  when  called  by  her  own  name,  and 
obstinately  refused  to  accept  the  visits  of  her  husband 
and  children,  whom  she  called  "  impostors.  "  Another 
patient,  afflicted  with  hysteria,  believed  herself  to  have 
been  transformed  into  a  dog;  she  barked  and  walked  on 
all  fours.  Still  another  patient  at  the  Salpetriere  re- 
ferred to  herself  as  "the  person  of  myself.  " 

Complete  transformation  of  the  personality  ma}^  be 
permanent,  constituting,  according  to  the  excellent  ex- 
pression of  Ribot,  a  true  alienation  of  the  personality; 
or  it  may  be  transitory,  so  that  the  new  ego  disappears 
at  a  certain  time  to  be  replaced  again  by  the  former 
ego.  In  cases  in  which  the  normal  personality  and  the 
pathological  one  replace  each  other  mutually  several 
times  we  have  variation  by  alternation.1 

Incomplete  transformation  of  the  personality  exists  in 
a  great  many  cases  in  which  the  patients  are  led  by  their 
delusions  to  attribute  to  themselves  imaginary  talents, 
powers,  or  titles,  without  at  the  same  time  completely 

1  Ribot.     TJw  diseases  of  persoJiality. 


SYMPTOMATOLOGY.  97 

abolishing  their  real  ego.  One  patient  suffering  from 
chronic  delirium  of  old  standing  claimed  that  he  was 
St.  Peter,  and  explained  that  he  had  been  incarnated  in 
an  earthly  man  for  the  purpose  of  bringing  happiness 
to  mankind.  A  general  paretic  claimed  that  he  was 
Emperor  of  Asia,  reigning  in  Pekin,  being  at  the  same 
time  aware  of  the  fact  that  he  was  living  in  Paris,  and 
was  a  newspaper  vender. 

Gamier  and  Dupre  have  described  under  the  name 
of  paroxysmal  mental  puerilism  1  "a  retrogression  of 
the  intellect  to  its  primitive  stages/ ;  a  state  in  which 
the  subject  once  more  becomes  psychically  a  child,  the 
transformation  being  only  a  temporary  one.  In  the 
observation  which  they  report  a  woman  of  thirty-three 
years  took  pleasure  in  childish  amusements,  such  as  play- 
ing with  dolls,  etc.,  and  expressed  herself  in  such  childish 
language  that  she  created  the  impression  "not  of  an 
adult  woman  of  thirty-three  years,  but  of  a  child  of 
.five  years."  This  interesting  syndrome  is  encountered 
in  the  most  diverse  affections.  It  may  be  met  with  in 
hysteria,  in  cerebral  tumors,  in  abscess  of  the  brain,  etc. 

(c)  Reduplication  of  the  personality  consists  in  the 
development  of  a  new  personality  of  a  parasitic  nature 
alongside  of  the  real  personality  of  the  patient. 

This  reduplication  is  the  origin  of  the  idea  of  posses- 
sion so  frequent  in  the  chronic  melancholic  deliria  and 
results  in  a  psychic  disaggregation  the  most  impor- 
tant manifestations  of  which  are  autochthonous  ideas 


1  Transformation  de  la  personnalite.     PiUrilisme  mental  paroxys- 
tique.     Presse  medicale,  1901,  No.  101. 


9$  MANUAL  OF  PSYCHIATRY. 

(psychic  hallucinations)  and  motor  hallucinations.  As 
I  have  had  occasion  to  indicate  above,  the  patient,  feel- 
ing that  he  is  losing  control  of  his  own  thoughts  and 
movements,  concludes  that  a  strange  personality  has 
taken  possession  of  him. 


CHAPTER  V. 

THE  PRACTICE  OF  PSYCHIATRY. 

EXAMINATION     OF    PATIENTS. —  GENERAL      THERA- 
PEUTICS OF   THE  PSYCHOSES. 

§  1.  Examination  of  Patients. 

The  data  for  the  diagnosis,  prognosis,  and  treatment 
are  obtained  in  psychiatry,  as  in  all  the  other  branches 
of  medicine,  from  the  anamnesis  and  from  the  direct 
examination  of  the  patient. 

The  anamnesis. — An  anamnesis  as  complete  as  possi- 
ble is  indispensable  for  an  accurate  diagnosis.  It  should 
be  based  upon  information  obtained  from  the  patient's 
relatives,  and  from  the  patient  himself  when  he  is  in  a 
condition  to  give  accurate  answers  concerning  the 
family  history  and  his  personal  history. 

A  knowledge  of  the  family  history  enables  us  to  deter- 
mine the  causes  of  inherited  or  simply  congenital  de- 
generation, to  the  influence  of  which  the  patient  has 
been  exposed.    • 

A  knowledge  of  the  personal  history,  still  more  im- 
portant, informs  the  physician:  (1)  as  to  whether  the 
disease  is  congenital  or  acquired;  (2)  in  the  case  of 
acquired  psychoses,  (a)  as  to  the  nature  of  the  soil 
(presence  or  absence  of  congenital  psychic  anomalies)- 
(b)  as  to  the  causes  of  the  disease;  (c)  as  to  its  mode  t 
of  onset  and  its  duration. 

99 


100  MANUAL   OF  PSYCHIATRY. 

It  is  customary  in  many  hospitals  to  obtain  from  the 
relatives  or  from  the  family  physician  replies  to  a 
definite  series  of  questions  on  regular  blanks.  Not- 
withstanding the  very  considerable  advantages  of  this 
method,  it  ought  not  to  be  used  exclusively ;  the  alienist 
should  not  neglect  in  addition  to  interrogate  personally 
all  those  who  are  in  a  position  to  furnish  further  infor- 
mation. 

Direct  examination  of  the  patient.1 — Three  classes 
of  cases  may  be  met  with: 

(1)  The  patient  himself,  realizing  his  condition,  applies 
to  the  physician;  the  examination  is  then  conducted 
by  a  routine  method. 

(2)  The  patient,  not  realizing  his  condition,  but  de- 
mented and  indifferent,  submits  passively  to  the  ex- 
amination. The  task  of  the  physician  is  rendered  some- 
what more  difficult  on  account  of  the  lack  of  precision 
and  veracity  in  the  information  furnished  by  the  subject. 

In  both  these  cases  it  is  justifiable  to  proceed  with  a 
methodical  examination  conducted  according  to  a  plan 
previously  laid  out. 

(3)  The  patient  does  not  realize  his  condition,  but  is 
lucid.  Being  convinced  that  he  enjoys  perfect  mental 
soundness,  he  does  not  understand  why  the  physician 
should  pry  into  his  personal  affairs,  and  refuses  to 
answer  questions  which  to  him  seem  useless  or,  worse 
still,  inspired  by  ill-will;  the  physician's  role  is  here 
very  delicate. 

He  must  endeavor  to  obtain  the  confidence  of  the 


[l  The  physical  examination  is,  of  course,  of  extreme  importance. 
For  the  methods  of  physical  examination  the  reader  is  referred  to 
standard  works  on  diagnosis,  neurology,  and  practice  of  medicine.] 


THE  PRACTICE  OF  PSYCHIATRY.  101 

patient,  and  the  best  means  of  doing  this  is  undoubtedly 
that  recommended  by  Regis:  he  should  introduce  him- 
self, frankly  as  a  physician  called  by  another  member 
of  the  family.  In  some  rare  cases  he  may  be  obliged 
to  conceal  the  fact  that  he  is  a  physician  and  to  intro- 
duce himself  as  a  fictitious  person  in  some  particular 
capacity  which  may  suggest  itself  in  the  given  case. 

In  such  cases  the  examination  is  often  limited  to  a 
simple  conversation  directed  so  as  to  furnish  the  greatest 
possible  amount  of  information  concerning  the  patient's 
mental  state.  An  important  rule  which  should  always 
be  remembered  is  never  to  dispute  the  patient's  delu- 
sions. It  may  be  useful  in  the  diagnosis  to  find  out 
how  the  patient  takes  the  disputing  of  his  delusions; 
but  all  such  attempts  require  extreme  prudence,  if  one 
wishes  to  avoid  irritatmg  the  patient  and  thus  hindering 
the  examination. 

Whichever  procedure  is  adopted,  methodical  ques- 
tioning or  conversation,  the  data  gathered  by  the 
physician  should  permit  of  establishing: 

(1)  The  degree  of  intellectual  development; 

(2)  The  state  of  the  consciousness  and  orientation; 

(3)  The  degree  of  insight  which  the  patient  may 
have  into  his  condition; 

(4)  Delusions,  if  any,  and  their  degree  of  systemati- 
zation; 

(5)  The  changes  of  the  affectivity  and  the  character 
of  the  patient's  tendencies. 

Some  commonly  employed  procedures  often  enable 
one  to  obtain  these  points  of  information  very  quickly. 
Such  are  questions  concerning  the  patient's  surround- 
ings, his  age,  his  occupation,  his  family. 


102  MANUAL  OF  PSYCHIATRY. 

The  three  questions,  "How  old  are  you?"  "In  what 
year  were  you  born?"  and  "What  year  is  this?"  put 
to  the  patient  successively  inform  us  by  the  degree 
of  accuracy  of  the  replies  obtained:  (1)  as  to  the 
patient's  orientation  of  time;  (2)  as  to  the  condition 
of  his  memory, — that  of  fixation  as  well  as  that  of 
conservation  and  reproduction;  (3)  as  to  the  condi- 
tion of  the  patient's  judgment,  by  the  presence  or 
absence  of  flagrant  contradictions  in  the  replies:  the 
patient  may  state,  for  instance,  that  he  is  fifty  years 
old,  was  born  in  1882,  and  that  the  present  year  is 
1902. 

Tests  of  reading  and  writing  are  also  very  use- 
ful. 

The  first  consists  in  requesting  the  patient  to  read 
aloud  some  paragraph  in  a  book  or  in  a  newspaper  and 
several  minutes  later  having  him  give  an  account  of 
what  he  has  read;  this  account  is  more  or  less  accurate 
and  complete.  This  test  may  demonstrate  any  exist- 
ing disorders  of:  (1)  perception;  (2)  attention  and  asso- 
ciations of  ideas;  (3)  the  power  of  fixation;  (4)  the 
patient's  speech  (physical  impediments). 

The  second  test,  that  of  writing,  consists  in  asking 
the  patient  to  write  something,  either  of  his  own  pro- 
duction or  from  dictation  or  copy.  This  test  furnishes 
information  not  only  concerning  the  degree  of  general 
intelligence  but  also  concerning  some  motor  functions 
(tremulous  or  irregular  handwriting),  and  often  con- 
cerning the  patient's  delusions. 

Thus  one  patient,  requested  to  write  a  letter  to  his 
family,  began  his  letter  with  the  following  very  sig- 
nificant words:   "In  the  name  of  the  Father,  the  Son, 


THE  PRACTICE  OF  PSYCHIATRY.  103 

and  the  Holy  Ghost,  We,  the  Emperor  of  Asia," 
etc.1 

Simulation  and  dissimulation.  —  The  physician,  *  in 
considering  the  question  of  insanity,  should  not  accept 
without  verification  the  statements  of  the  subject  pre- 
sented to  him  for  examination,  for  he  may  be  a 
simulator  or  a  dissimulator. 

It  is  often  very  difficult  to  discover  simulation. 
Undoubtedly  most  individuals  who  practice  it,  being 
but  little  informed  on  insanity,  do  not  represent  the 
known  types  of  psychoses:  the  attitudes,  the  gestures, 
the  reactions,  and  the  conversation  present  a  constrained, 
affected  aspect  of  voluntary  exaggeration  which  at  the 
very  start  may  arouse  the  suspicions  of  the  physician. 
Still  the  clinical  types  are  as  yet  but  poorly  defined  in 
psychiatry,  and  it  would  be  extremely  imprudent  to 
declare  the  existence  of  simulation  merely  from  an 
unusual  combination  and  character  of  the  symptoms. 
Affectation  in  action  and  in  speech,  extreme  incoher- 
ence, apparently  voluntary,  are  seen  in  catatonia; 
the  agitation  of  certain  hysterical  patients,  and  even 
of  some  maniacs,  often  increases  when  the  patients  feel 
themselves  being  observed. 

The  principal  elements  upon  which  the  diagnosis  of 
simulation  is  to  be  based  are  as  follows: 

(a)  The  existence  of  a  motive :  legal  prosecution,  some 
sentence  or  punishment  which  the  subject  may  seek  to 
escape  or  military  service  which  he  may  wish  to  evade; 

[x  The  above  are  but  the  general  directions  for  a  hasty  procedure 
leading  merely  to  the  determination  of  the  absence  or  presence  of 
mental  derangement.  For  the  methods  of  obtaining  a  complete 
mental  status,  see  Sommer's  Diagnostic  der  Geisteskrankheiten.] 


104  MANUAL   OF   PSYCHIATRY. 

(b)  The  sudden  appearance  of  the  symptoms  (agi- 
tation, delusions,  confusion,  stupor),  without  prodro- 
mata,  which  is  very  rare  in  the  psychoses; 

(c)  The  constant  observation  of  the  subject  whose 
conduct  is  often  in  discord  with  his  delusions  or  with 
his  simulated  disorder  of  affectivity;  a  pseudo-melan- 
choliac,  who  declares  himself  the  greatest  criminal  on 
earth,  loudly  demands  to  be  put  to  death,  and  refuses 
food,  will  hide  himself  in  a  corner  to  devour  with  avidity 
a  piece  of  bread  stolen  from  another  patient,  and  will 
sleep  quietly  when  alone  in  his  room  believing  himself 
to  be  unobserved.  A  similar  contradiction  is  encoun- 
tered in  certain  established  dementias,  but  never  in 
the  beginning  of  psychoses. 

However,  the  certainty  of  simulation,  even  when 
based  upon  the  confession  of  the  subject,  does  not 
necessarily  indicate  that  the  subject  is  a  normal  and 
fully  responsible  individual.  The  idea  itself  of  simulat- 
ing a  mental  affection  can  arise  only  in  an  individual 
who  is  psychically  abnormal.  Joffroy  quotes  a  remark 
of  Lasegue:  "One  must  be  morbid  to  be  a  simulator 
of  insanity." 

Dissimulation  x  is  the  opposite  of  simulation.  Certain 
of  the  insane,  almost  always  of  the  dangerous  class, 
such  as  paranoiacs  with  ideas  of  vengeance  or  melan- 
choliacs  with  ideas  of  suicide,  make  efforts  to  conceal 
their  morbid  tendencies  by  assuming  an  outward 
appearance  of  calmness  or  even  of  happiness.  They 
pretend  never  to  have  shown,  or  at  least  to  have  re- 
covered from,  the  mental  disorders  attributed  to  them; 

■» . 

1  Pasquet.     Les  alicncs  dissimulateurs.     These  de  Paris,  1898 


THE  PRACTICE  OF   PSYCHIATRY.  105 

some  admit  having  been  ill,  but  affirm  that  it  is  all  over 
and  that  they  think  no  more  of  "  their  former  follies. " 
These  patients  are  sometimes  spoken  of  as  being  reticent. 
Only  the  most  intelligent  and  painstaking  observation 
of  all  the  details  of  the  case  will  enable  one  to  recognize 
dissimulation;  the  attitudes  and  gestures  of  the  patient 
must  be  taken  into  account,  his  soliloquies  or  conver- 
sations with  the  " invisibles"  to  whom  he  abandons 
himself  when  he  thinks  he  is  alone,  and  finally  his 
writings.  The  latter  are  of  primary  importance: 
many  dissimulators  who  conceal  their  ideas  in  conver- 
sation do  not  hesitate  to  put  them  on  paper  in  the 
form  of  memoranda  or  of  letters  to  editors  of  periodicals 
or  to  government  officials. 

§  2.  General  Therapeutic  Indications  :  Sanitari- 
ums.— Commitment. — Treatment  of  Excitement, 
of  Suicidal  Tendencies,  and  of  Refusal  of 
Food. 

There  is  no  particular  treatment  suitable  for  all 
mental  diseases  any  more  than  there  is  for  all  affections 
of  the  stomach  or  of  the  kidneys.  Certain  therapeutic 
indications,  however,  are  of  such  importance  and 
frequency  that  it  would  be  of  use  to  make  a  general 
study  of  them. 

Some  are  relative  to  the  surroundings  in  which  the 
patients  should  be  placed,  others  to  certain  particularly 
grave  manifestations  of  mental  diseases:  excitement, 
suicidal  ideas,  and  refusal  of  food. 

Surroundings:  sanitarium  commitment. — It  is  neces- 
sary in  most  of  the  psychoses  to  procure  for  the  patient 
absolute  physical  and  intellectual  repose  and  to  relieve 


106  MANUAL  OF  PSYCHIATRY. 

him  so  far  as  possible  from  his  preoccupations,  delu- 
sional or  rational. 

These  indications  are  difficult  to  carry  out  in  the 
ordinary  conditions  of  life.  The  obstacles  are  of  a 
nature  both  material  and  moral .  material,  because  only 
few  families  can  afford  the  expense  involved  in  the 
treatment  of  an  insane  patient  at  home;  and  moral, 
because  the  relatives,  inexperienced  in  the  treatment 
of  mental  diseases,  are  not  likely  to  carry  out  properly 
all  the  orders  of  the  physician,  and  may  cause  an  aggra- 
vation of  the  patient's  condition  by  yielding  to  all  his 
caprices,  being  under  the  impression  that  he  must  not 
be  contradicted,  and  by  wearying  him  in  their  attempts 
to  reason  with  him  or  to  distract  him. 

The  removal  to  a  sanitarium  is  therefore  in  most 
cases  inevitable. 

All  insane  patients  may  be  grouped  in  two  classes: 
the  inoffensive  and  the  dangerous. 

For  the  first  class  of  cases  the  sanitarium  does  not 
present  any  particular  features  and  the  admission  of 
the  patient  is  effected  with  no  more  formality  than 
that  into  a  general  hospital. 

The  patients  of  the  second  class  must  be  committed 
or  isolated;  this  must  be  accomplished  under  the  super- 
vision and  responsibility  of  a  public  authority,  and 
entails  certain  formalities.1  ' 

Of  all  these  formalities  only  one  is  of  interest  to  us 
here:  the  physician's  certificate  of  lunacy. 


['  The  original  text  here  contains  an  extensive  quotation  of  the 
French  insanity  law;  for  obvious  reasons  it  has  been  obmitted  in 
the  translation.] 


THE  PRACTICE  OF   PSYCHIATRY.  107 

The  certificate,  intended  to  establish  the  legitimacy 
of  the  commitment,  need  not  contain  any  detailed 
observations  and  does  not  necessarily  involve  a  precise 
clinical  diagnosis.  It  is  of  little  importance  here 
whether  the  patient  does  or  does  not  present  inequality 
of  the  pupils  or  abolition  of  the  patellar  reflexes.  It 
is  also  unimportant  whether  he  suffers  from  mania  or 
from  dementia  prsecox,  as  long  as  the  symptoms  which 
he  presents  render  him  a  menace  to  himself,  to  others, 
or  to  the  public  peace. 

The  indications  for  commitment  are  chiefly  to  be 
based  on  the  dangerous  tendencies  of  the  patient:  a 
senile  dement  who  is  quiet  and  tractable  can  without 
any  inconvenience  be  cared  for  at  home  or  in  an  asylum 
for  old  men;  another  who  is  on  the  contrary  irritable 
and  violent  should  be  committed  without  hesitation. 

In  a  general  way  the  following  symptoms  should  be 
considered  as  indications  for  commitment:  impulsive 
tendencies;  suicidal  ideas;  ideas  of  persecution  and 
hallucinations  which  bring  about  violent  reactions; 
states  of  dementia  associated  with  phenomena  of 
excitement. 

The  character  and  intensity  of  the  symptoms  should, 
however,  not  be  the  only  factors  governing  the  action 
of  the  physician.  He  should  also  take  into  account 
their  probable  duration.  If  the  mental  disorder  is  not 
likely  to  persist  for  more  than  several  days  and  has 
no  tendency  to  recur  frequently,  commitment  is  not 
justifiable;  such  is  the  case  in  febrile  deliria. 

Transfer  of  the  patient  to  the  asylum. — Undoubtedly 
it  is  the  physician's  duty  to  induce  the  patient  to  go 
to  a  hospital.    Unfortunately  this  is  not  always  easy 


108  MANUAL   OF  PSYCHIATRY. 

or  even  possible  when  the  question  is  one  of  commitment. 
If  the  patient  is  lucid,  as  in  cases  of  chronic  delirium 
or  paranoia,  one  is  often  compelled,  in  order  to  avoid 
painful  scenes,  to  resort  to  certain  subterfuges,  such 
as  proposing  to  conduct  him  to  some  place  where  he 
desires  to  go,  or  inviting  him  to  go  out  on  an  excursion. 
This  question,  at  times  delicate,  cannot  of  course  have 
a  universal  solution. 

Medico-legal  testimony. — The  purpose  of  medico- 
legal testimony  is  to  inform  the  public  official,  most 
frequently  a  judiciary  authority,  as  to  the  mental 
state  of  the  individual  submitted  to  an  examination  by 
an  expert,  and  particularly  as  to  his  responsibility. 
The  word  "  responsibility "  is  used  here  not  in  a  meta- 
physical sense,  but  in  a  practical  one,  and  is  to  be 
defined  as  "the  faculty  of  adapting  (so  far  as  possible) 
our  mental  life  to  the  external  world,  and  especially 
of  adapting  our  mental  life  to  that  of  other  individuals."1 
According  to  this  definition  any  individual  should 
be  declared  irresponsible  who  presents  psychic  anoma- 
lies which  prevent  his  "  adapting  himself  to  the  external 
world  and  to  life  in  society."  Thus  understood  respon- 
sibility has  an  infinite  number  of  degrees.  In  fact 
"  between  those  who  adapt  themselves  very  well  and 
those  who  cannot  adapt  themselves  at  all  there  are 
all  those  who  can  adapt  themselves,  but  imperfectly, 
only  to  certain  aspects  of  social  life:  persons  having 
but  a  limited  responsibility.     Between  these  two  ex- 


1  Forel.  Ueber  die  Zurechnungsfahigkeit  des  normalcn  Menschen. 
Munich,  L901. — Forel  et  Mahaim.  Crime  et  anomalies  mentales 
coiislUutionellc.'i,   1902,  Paris,  F.   Alcan. 


THE  PRACTICE  OF  PSYCHIATRY.  109 

tremes   are   all   the   imaginary    transitions   that  exist 
between  perfect  health  and  disease"  (Mahaim). 
The  medico-legal  report  comprises: 

(1)  A  study  of  the  subject's  personality  and  of  the 
modifications  which  it  has  undergone,  if  any; 

(2)  In  criminal  cases,  a  study  of  the  offenses  for 
which  he  is  indicted,  or  upon  which  the  parties  con- 
cerned base  their  accusations  against  the  subject  or 
their  demands  to  annul  agreements  or  engagements 
that  they  may  have  made  with  him; 

(3)  Where  possible,  a  precise  diagnosis  and  prognosis; 

(4)  Finally,  conclusions  as  to  the  degree  of  responsi- 
bility which  may  be  attributed  to  the  subject. 

The .  information  which  should  guide  the  expert  in 
making  out  the  report  is  derived  from  four  principal 
sources : 

(1)  The  direct  examination  and  (2)  prolonged  obser- 
vation of  the  subject.  This,  to  be  of  real  value,  should 
be  conducted  in  a  hospital.  Indeed  a  great  many 
important  peculiarities  in  the  conduct  and  conversation 
of  a  subject  submitted  for  an  expert's  examination 
remain  unnoticed  by  persons  inexperienced  in  insanity, — 
prison  guards,  for  instance; 

(3)  The  expert's  inquiries  from  persons  who  are  in 
a  position  to  furnish  information  concerning  the  patient ; 

(4)  A  judiciary  inquiry  the  data  of  which  the 
physician  is  a  priori  obliged  to  accept  as  true  in  the 
absence  of  other  evidence.  The  importance  of  the 
judiciary  inquiry  is  extreme  and  in  many  cases  furnishes 
the  essential  element  of  diagnosis.  For  instance,  in 
the  case  of  a  crime  committed  by  a  paranoiac  whose 
entire  derangement  consists  in  a  single  false  idea  which 


110  MANUAL  OF  PSYCHIATRY. 

does  not  always  appear  as  an  absurd  idea  on  first  con- 
sideration, only  the  judiciary  inquiry  can  determine 
whether  the  allegations  of  the  patient  are  true  or  not. 

TREATMENT  OF   EXCITEMENT. 

Perhaps  the  greatest  progress  in  the  therapeutics  of 
mental  diseases  within  the  past  few  years  has  been 
made  in  our  methods  for  the  treatment  of  excitement. 

Little  by  little  means  of  restraint,  always  useless, 
often  barbarous,  have  disappeared  from  asylums. 

The  honor  of  having  introduced  into  France  the 
"no  restraint/ '  or  treatment  of  excitement  without 
mechanical  restraint,  belongs  to  Magnan  (1867). 

The  methods  employed  to-day  in  combating  excite- 
ment may  be  grouped  under  four  principal  headings: 

Rest  in  bed; 

Hydrotherapy ; 

Isolation; 

Medication. 

Rest  in  bed.1 — First  used  in  melancholia  (Guislain, 
Griesinger,  Ball),  rest  in  bed  has  been  only  since  recently 
employed  in  the  treatment  of  excitement.  Magnan 
has  introduced  its  use  into  France,  after  having  shown 
the  excellence  of  its  effects  and  the  relative  facility  of 
its  employment. 

Rest  in  bed  presents  the  triple  advantage  of  saving 
the  patient's  energy,  calming  the  excitement,  and  facilitat- 
ing supervision.  It  is  indicated  in  most  of  the  acute 
psychoses  and  in  the  periods  of  exacerbation  of  chronic 


1  Pochon.     These    de    Paris,   1899. — Wizel.     Ann.    med.    psych., 
1901. — Serieux  et  Farnaricr.     Ann,  mcd.  psych.,  1900. 


THE   PRACTICE   OF  PSYCHIATRY.  Ill 

psychoses.  Rest  in  bed  need  not  necessarily  be  con- 
stant to  be  efficacious,  except  in  cases  in  which  the 
gravity  of  the  general  condition  requires  it.  It  is  well 
to  allow  patients  to  get  up  for  two  or  three  hours  daily, 
using  part  of  the  time  for  outdoor  walks  the  duration 
of  which  is  to  be  determined  by  the  special  indications 
in  each  case. 

Rest  in  bed  produces  the  best  effects  when  carried 
out  collectively  in  small  dormitories  containing  not  more 
than  ten  beds.  The  example  of  patients  who  have 
already  submitted  to  this  mode  of  treatment  exercises 
a  salutary  influence  upon  the  newcomers  and  helps  to 
induce  them  also  to  accept  it.  Under  favorable  con- 
ditions two  or  three  days  generally  suffice  for  even  a 
very  excited  maniac  to  become  accustomed  to  staying 
in  bed,  and  to  become  calmed  to  a  certain  extent. 

Though  he  may  still  persist  in  restless  movements,  he 
rarely  leaves  his  bed,  and  when  he  does,  he  will  return 
without  difficulty  upon  the  simple  injunction  of  the  nurse. 

Hydrotherapy. — The  cold  douche,  formerly  much  em- 
ployed for  calming  excitement,  acts  chiefly  by  its 
asphyxiating  effect.  It  is  therefore  not  surprising  that 
it  has  been  entirely  abolished. 

Of  the  various  forms  of  hydrotherapy  two  are  most 
frequently  used:  the  wet  pack  and  the  prolonged  warm 
bath. 

-  The  wet  pack  is  applied  by  means  of  a  sheet  soaked 
in  cold  water  and  closely  wrapped  around  the  entire 
body.  Its  duration  varies  from  twenty  minutes  to 
several  hours.  If  too  prolonged  it  may  cause  attacks 
of  syncope. 

Prolonged  warm  baths  are  of  great  service  when  rest 


112  MANUAL  OF  PSYCHIATRY. 

in  bed  does  not  suffice  to  calm  the  patient.  As  gener- 
ally used  their  duration  does  not  surpass  five  or  six 
hours  daily.  Some  physicians,  however,  have  obtained 
good  results  from  the  permanent  warm  bath:  the  patient 
remains  in  the  bath  for  days  or  weeks.1 

Most  alienists  have  abandoned  the  old-fashioned  cov- 
ered bath-tubs  intended  to  imprison  the  patient.  If 
necessary  he  is  simply  kept  in  by  several  nurses  until 
the  calming  effect  of  the  bath  becomes  apparent. 

Isolation. — Much  combated  of  late,  isolation  presents, 
in  fact,  certain  inconveniences,  the  gravest  of  which  is 
leaving  the  patient  by  himself  without  constant  super- 
vision; it  is  absolutely  contraindicated  in  patients  with 
suicidal  tendencies,  and  should  not,  as  a  rule,  be  em- 
ployed until  the  other  measures, — rest  in  bed  and  pro- 
longed baths, — have  been  tried. 

Nocturnal  isolation  consists  in  allowing  the  patient  to 
sleep  in  a  separate  room  which  should,  of  course,  be 
conveniently  accessible  to  the  attendant;  it  is  of  great 
utility  in  certain  chronic  disturbed  patients.  Many  a 
dement  who  makes  a  great  deal  of  noise  during  the  night 
in  the  dormitory  will  repose  quietly  when  he  is  alone. 

Medication. — I  shall  limit  myself  to  the  mention  of 
those  drugs  which  are  most  frequently  used  in  states 
of  excitement,  and  to  giving  several  formulas. 

Opium  in  all  its  forms  is  used  for  the  insane:  extract 
of  opium  in  pills,  aqueous  solutions  for  subcutaneous 
injections,  tincture  of  opium,  etc. 

The  danger  of  forming  the  habit  prevents  the  use  of 
morphine  in  cases  requiring  prolonged  treatment. 


1  Sorieux.     Le  traitement  des  Mats  d'agitation  par  le  bain  per- 
manent.    Revue  de  Psychiatric,  Feb.,  1902. 


TEE   PRACTICE  OF  PSYCHIATRY.  113 

Chloral  enjoys  a  merited  reputation.  It  is  adminis- 
tered in  solution  by  the  mouth  in  doses  of  from  two 
to  three  grams  for  women  and  from  three  to  four  grams 
for  men,  or  per  rectum  in  doses  of  from  four  to  five 
grams  for  women  and  from  five  to  six  grams  for  men. 

Chloral  hydrate 2-4  grams 

Syrup  of  currant-berries 30 

Water,  enough  to  make 60  c.c. 

To  be  administered  in  one  or  two  doses  by  the  mouth. 

Chloral  hydrate 5  grams 

Yolk  of  egg .• 1 

Milk 120  grams 

To  be  administered  per  rectum,  preceded  by  a  simple 
enema. 

Chloral  may  be  combined  with  bromides: 

Chloral  hydrate 2  grams 

Potassium  bromide 4 

Syrup  of  currant-berries 30      " 

Water,  enough  to  make 80  c.c. 

To  be  administered  in  one  or  two  doses  by  the  mouth. 

Chloral  should  be  absolutely  prohibited  in  cases  of 
heart-disease. 

Bromides  may  also  be  used  alone  in  doses  of  from 
two  to  eight  grams. 

Sulphonal,  trional,  and  tetronal  bring  about  calm  and 
prolonged  sleep  in  cases  of  moderate  excitement,  given 
in  doses  of  one,  two,  or  three  grams.  They  are  usually 
administered  in  powders  each  containing  one  gram  of 
any  one  of  these  hypnotics.  One,  two,  or  three  such 
powders,  according  to  the  case,  is  to  be  administered 


114  MANUAL  OF  PSYCHIATRY. 

in  the  evening  towards  six  o'clock,  the  action  of  these 
drugs  being  slow. 

Chloralose,  hypnal,  and  somnal  may  also  be  of  service. 

Chloralose 20  to  60  centigrams. 

Given  in  a  powder. 

Hypnal 2  grams 

Chloroform-water 100      " 

Syrup  of  peppermint : 30      " 

To   be   administered   in   two   or   three   doses  by   the 

mouth.     (Debove  and  Gourin.) 

Somnal 2  grams 

Syrup  of  currant-berries 40      " 

Water 20.    " 

To  be  administered  like  the  preceding.     (Debove  and 

Gourin.) 

Paraldehyde  may  be  given  by  the  mouth,  by  the  rec- 
tum, or  hypodermically  in  doses  of  from  2  to  5  grams. 
It  is  an  excellent  hypnotic.  Its  only  inconvenience  is 
the  disagreeable  and  persistent  odor  which  it  imparts 
to  the  breath. 

Paraldehyde 2-5  grams 

Rum 20        " 

Lemon-juice 20  drops 

Simple  syrup 30  grams 

Distilled  water 40      ' ' 

To  be  administered  in  one  or  two  doses  by  the  mouth. 

(Debove  and  Gourin.) 

Paraldehyde 4  grams 

Yolk  of  egg 1 

Milk. 120  grams 


THE  PRACTICE  OF  PSYCHIATRY.  115 

To  be  administered  in  one  dose  per  rectum,  preceded 
by  a  simple  enema. 

Paraldehyde.  . 5  grams 

Cherry  laurel- water 5      l ' 

Boiled  distilled  water 15      " 

For  hypodermic  injection. 

Hyoscine  [hydrobromate  or]  hydrochlorate  is  a  very  active 
drug  and  must  be  used  with  great  caution.  It  may  be 
administered  in  solution,  in  pills,  or  by  subcutaneous 
injection. 

Hydrochlorate  of  hyoscine 0.005  gram 

Syrup  of  peppermint 30  grams 

Water  enough  to  make 120  c.c. 

A  tablespoonful  every  ten  minutes  until  five  doses  have 

been  given. 

Hyoscine  hydrobromate 0 .  02  gram 

Water 20  grams 

For  subcutaneous  injection. 

One  ordinary  hypodermic  syringeful  contains  one  mil- 
ligram of  the  drug.  Half  a  syringeful  is  given  at  first; 
it  is  very  rare  that  the  sedative  effect  is  not  produced 
by  a  whole  syringeful. 

SUICIDAL  TENDENCIES. 

Suicide  among  the  insane  is  perhaps  the  greatest 
source  of  anxiety  to  the  practical  alienist.1 
All  the  forms  of  mental  alienation,  excepting  perhaps 

1  Viallon.     Suicide  et  folie.     Ann.  med.  psych.,  1901. 


116  MANUAL  OF  PSYCHIATRY. 

mania,  may  give  rise  to  ideas  of  suicide,  but  the  first 
place  from  this  standpoint  belongs  to  psychoses  of  the 
depressed  form  (affective  melancholia,  depressed  form 
of  manic  depressive  insanity,  certain  forms  of  alcohol- 
ism, etc.). 

Whatever  the  nature  of  the  disease  may  be,  ideas  of 
suicide  may  result : 

(a)  From  an  imperative  hallucination:  a  voice  calls 
the  patient  to  heaven,  orders  him  to  die  in  atonement 
for  his  sins,  etc.; 

(b)  From  a  delusion:  fear  of  death  from  starvation, 
of  being  afflicted  with  an  incurable  disease;  some  pa- 
tients commit  suicide  to  escape  the  imaginary  persecu- 
tions of  their  enemies; 

(c)  From  an  unconquerable  disgust  for  existence 
(tedium  vita?)  or  from  an  intolerable  moral  pain; 

(c?)  From  a  sudden  impulse  (catatonia) ; 

(e)  From  a  suggestion:  family  suicide,  epidemics  of 
suicide ; 

(/)  From  a  fixed  idea,  the  origin  of  which  is  inex- 
plicable. Such  is  the  case  reported  by  Ferrari:  An 
officer  declared  on  several  occasions  that  it  was  ridicu- 
lous to  live  beyond  sixty  years.  On  the  last  day  of  his 
sixtieth  year,  after  having  passed  a  merry  evening  with 
his  friends,  he  announced  his  intention  of  committing 
suicide.  He  went  into  his  room  and  shot  himself  with 
a  revolver. 

The  smallest  objects  may  become  in  the  hands  of 
patients  deadly  weapons  which  they  may  turn  against 
themselves.  Magnan  reported  a  case  of  a  melancholiac 
who  perforated  his  heart  by  means  of  a  needle  measur- 
ing scarcely  3  centimeters  in  length.     Some  insane  in- 


THE   PRACTICE  OF  PSYCHIATRY.  117 

dividuals  at  times  resort  to  procedures  so  horrible  that 
their  use  cannot  be  explained  otherwise  than  by  the 
existence  of  marked  anesthesia;  thus  a  patient  of 
Baillarger's  applied  his  forehead  to  a  red-hot  plate  of 
iron. 

In  asylums,  where  the  patients  are  not  allowed  to 
have  in  their  possession  any  dangerous  instruments,  the 
means  most  frequently  made  use  of  is  hanging,  which 
fact  is  explained  by  the  extreme  simplicity  of  the  pro- 
cedure. 

Together  with  suicide  may  be  classed  the  self-mutila- 
ations  which  patients  frequently  commit. 

Insane  patients  have  been  observed  to  cut  off  their 
own  fingers,  lacerate  or  even  cut  off  their  genital 
organs  by  means  of  pieces  of  glass,  open  their  abdo- 
mens, etc. 

The  treatment  of  suicidal  tendencies  is  reduced  to 
strict  and  constant  watching,  which  should  be  insti- 
tuted as  soon  as  the  existence  of  such  tendencies  is 
suspected,  and  continued  for  a  long"  time  after  their 
apparent  disappearance.  As  we  have  already  stated 
above,  isolation  is  absolutely  contraindica'ted.  Keep- 
ing the  patient  in  the  observation  ward  and  rest  in  bed 
during  the  acute  periods  are  very  useful  measures. 

REFUSAL  OF  FOOD    (SITIOPHOBIA). 

Refusal  of  food  *  may  result  from: 

(a)  Delusions  with  or  without  coexisting  hallucina- 

1  Pfister.  Die  Abstinenz  der  Geisteskranken  und  Hire  Behandlung, 
Freiburg,  1899. 


118  MANUAL  OF  PSYCHIATRY. 

tions:    fear  of  being  poisoned  or  of  not  being  able  to 
digest  the  food;    hypochondriacal  ideas; 
(6)  The  desire  to  starve  to  death; 

(c)  An  unconquerable  disgust  for  food; 

(d)  Negativism  (catatonia,  general  paresis). 
Refusal  of  food  may  be  partial  or  complete.    Some 

patients  will  accept  only  certain  kinds  of  food,  often 
because  these  appear  to  them  to  be  the  safest  or  because 
"the  voices"  order  them  so.  One  patient  lived  solely 
on  eggs,  the  shell  seeming  to  him  to  be  the  only  impene- 
trable barrier  to  the  mysterious  agencies  used  by  his 
persecutors. 

It  may  be  also  absolute  or  relative.  Often  with  a 
little  perseverance  one  may  persuade  a  melancholiac 
to  accept  a  sufficient  quantity  of  nourishment  in  a  con- 
venient form.  Some  catatonics  refuse  what  they  have 
been  offered  and  several  minutes  later  devour  their 
neighbor's  meal  without  there  being  any  delusion  to 
explain  their  conduct. 

When  the  refusal  of  food  threatens  to  have  a  bad 
effect  upon  the  health  of  the  patient,  as  is  shown  by 
loss  of  weight  determined  by  systematic  weighings,  one 
must  resort  to  forced  feeding  or  "  tube-feeding. ;; 

Tube-feeding  may  be  accomplished  in  two  ways: 
by  the  nose  and  by  the  mouth. 

Tube-feeding  by  the  mouth  is  the  less  painful  and  less 
dangerous  procedure  for  the  patient  as  well  as  the  most 
convenient  one  for  the  physician. 

The  necessary  mstruments  are  a  mouth-gag,  a  stomach- 
tube,  and  a  glass  or  rubber  funnel. 

The  operation  itself  is  performed  in  four  stages: 

(1)  Opening  the  mouth; 


THE  PRACTICE  OF  PSYCHIATRY.  119 

(2)  Introducing  the  tube  into  the  stomach; 

(3)  Attaching  the  funnel  to  the  tube  and  tests  for 
ascertaining  the  proper  penetration  of  the  tube  into 
the  stomach; 

(4)  Introducing  the  liquid  food. 

The  first  stage  presents  several  difficulties  due  to  the 
resistance  of  the  patient,  which  is  at  times  very  great. 
However,  by  using  patience  and  taking  advantage  of 
the  little  interstices  between  the  jaws,  it  is  always 
possible  to  accomplish  this. 

The  introduction  of  the  tube  is  usually  easy.  The 
end  entering  the  pharynx  sets  up  reflexly  the  move- 
ments of  deglutition,  so  that  the  instrument  of  itself 
enters  the  oesophagus.  A  gentle  push  suffices  to  make 
it  enter  the  stomach. 

Although  the  large  size  of  the  tube  renders  a  false 
passage  almost  impossible,  the  purpose  of  the  third 
stage  is  to  ascertain  that  the  tube  is  well  in  place  and 
has  not  entered  the  trachea.  Two  procedures  are 
used  to  make  sure  of  this:  auscultation  at  the  opening 
of  the  funnel  and  introduction  into  the  tube  of  several 
drops  of  pure  water.  If  the  noise  produced  by  the 
gases  of  the  stomach  is  heard,  and  if  the  water  runs 
down  freely,  the  tube  is  in  place  and  is  not  obstructed. 
Otherwise  the  tube  must  be  withdrawn  and  cleaned 
and  the  operation  recommenced. 

The  liquid  nourishment  should  always  be  introduced 
at  a  low  pressure.  Its  composition  may  vary  accord- 
ing to  individual  cases.  Milk,  eggs,  beef -juice,  peptones, 
or  vegetable  soups  usually  constitute  the  basis. 

Tube-feeding  through  the  nasal  passages  presents 
several  inconveniences: 


120  MANUAL  OF  PSYCHIATRY. 

(1)  It  is  painful; 

(2)  It  causes  quite  often  irritation  and  inflammation 
of  the  nasal  mucosa; 

(3)  The  small  dimensions  of  the  tube  render  its  intro- 
duction into  the  larynx  easy,  and  do  not  allow  the  use 
of  any  but  perfectly  liquid  food. 

This  method  of  feeding  should,  therefore,  not  be 
resorted  to  except  in  special  cases,  such  as  those  of 
buccal  affections  interfering  with  the  introduction  of 
the  tube  by  the  mouth. 

Not  infrequently  after  tube-feeding  the  patient  rejects 
the  contents  of  the  stomach  either  spontaneously  or  by 
a  voluntary  effort.  This  may  often  be  prevented  by 
throwing  a  few  drops  of  water  at  his  face.  In  cases 
of  obstinate  vomiting  the  irritability  of  the  stomach 
mucosa  may  be  diminished  by  introducing  with  the 
liquid  food  several  drops  of  a  solution  of  cocaine. 

It  may  be  useful  to  precede  the  feeding  by  lavage  of 
the  stomach. 


PART  II. 

SPECIAL  PSYCHIATRY. 


CLASSIFICATION. 

Pathological  anatomy  is  the  only  criterion  that 
enables  us  to  establish  in  the  diseases  of  an  organ 
categories  corresponding  to  reality.  The  lesions  of 
most  of  the  psychoses  being  unknown,  each  school 
assumes  the  right  to  create  a  classification  corresponding 
with  its  tendencies,  which  may  be  more  or  less  ingenious, 
but  is  necessarily  artificial. 

Of  all  those  offered  to  us  by  psychiatry  it  would  be 
best  to  select  the  most  practical,  the  most  convenient, 
and  the  one  which  in  a  given  case  would  enable  us 
most  easily  to  establish  the  prognosis  and  to  institute  the 
treatment.  The  classification  of  Kraepelin  appears 
to  me  to  present  great  advantages  from  this  stand- 
point. 

I  shall  therefore  adopt  it  here  with  some  modifications, 
which  shall  be  indicated  in  the  course  of  this  work. 

The  following  are  the  morbid  entities  described  in 

this  manual,  enumerated  in  the  order  which  I  propose 

to  follow. 

121 


122  MANUAL  OF  PSYCHIATRY. 

I.  Infectious  psychoses: 

Febrile  delirium; 
Infectious  delirium; 
Hydrophobia. 

II.  Psychoses  of  exhaustion: 

Mental  confusion;  acute  delirium. 

III.  Toxic  psychoses: 

(a)  Acute: 

Pathological  drunkenness. 

(b)  Chronic: 

Alcoholism; 
Morphinomania ; 
Cocainomania. 

IV.  Psychoses  of  autointoxication: 

(a)  Acute:   Uraemia; 

(b)  Subacute:   The  polyneuritic  psychosis. 

(c)  Chronic:   Myxoedema; 

Dementia  prsecox;  chronic  delirium; 
General  paresis. 

V.  Psychoses  dependent  upon  so-called  organic 

CEREBRAL  AFFECTIONS^ 

Arteriosclerosis;    cerebral    tumors;    cerebral 
syphilis;    hemorrhages;   softenings. 

VI.  Psychoses  of  involution: 

Affective  melancholia; 
Senile  dementia. 

VII.  Psychoses  without  a  well-determined  eti- 
ology, WHICH  ARE  APPARENTLY  BASED  UPON  A  MORBID 

PREDISPOSITION  *. 

Manic  depressive  insanity; 
Paranoia. 


CLASSIFICATION.  123 

Constitutional  psychopathic  conditions: 
Mental  instability; 
Sexual  perversions  and  inversions; 
Obsessions. 

VIII.  Psychoses  based  upon  neuroses: 

Epilepsy; 
Hysteria. 

IX.  Arrests  of  mental  development: 

Idiocy  and  imbecility; 
Moral  insanity. 


CHAPTER  I. 
DELIRIA  OF  INFECTIOUS  ORIGIN.1 

The  mental  disorders  which  appear  in  the  course  of 
infectious  diseases  are  brought  about  by  the  combined 
action  of  several  factors:  elevation  of  temperature, 
congestion  of  the  nervous  centers,  and  poisoning  of 
these  centers  by  microbic  toxines.  The  most  important 
factor  appears  to  be  the  poisoning  of  the  nervous 
centers. 

One  cannot  fail  to  notice  the  striking  clinical  resem- 
blance existing  between  the  toxic  deliria,  properly  so 
called,  and  the  infectious  deliria;  indeed  the  resemblance 
is  so  close  that  without  the  somatic  symptoms  peculiar 
to  each  condition  it  would  be  difficult  or  even  impossible 
to  make  the  differentiation.  Notes  on  such  cases 
almost  always  describe  the  same  symptoms:  clouding 
of  consciousness,  confusion,  numerous  illusions  and 
hallucinations,  motor  agitation. 

Moreover,  the  infection  itself,  independently  of 
hyperpyrexia  and  probably  of  any  meningeal  lesion, 
may  cause  grave  mental  disorders  (infectious  delirium 
proper)  which  can  only  be  explained  by  a  toxic  action. 

1  Klippel  et  Lopez.  Du  reve  et  du  delire  qui  lui  fait  suite  dans 
les  infections  aigues.  Rev.  de  Psychiatrie,  April  1900. — Desvaux. 
Delire  dans  les  maladies  aigues.     These  de  Paris,  1899. 

124 


DELIRIA  OF  INFECTIOUS  ORIGIN.  125 

After  the  description  of  febrile  delirium  I  shall  say  a 
few  words  with  regard  to  infectious  delirium  proper. 
I  shall  also  give  a  brief  description  of  the  mental  dis- 
orders of  hydrophobia,  which,  though,  like  the  preced- 
ing, they  belong  to  the  group  of  infectious  psychoses, 
merit  a  special  description  on  account  of  their  constancy 
and  their  peculiar  aspect. 

Febrile  delirium. — In  febrile  affections  the  psychic 
disorders  are  usually  limited  to  a  slight  degree  of  cere- 
bral torpor  and  of  irritability  of  humor.  Slight  noc- 
turnal agitation,  a  few  illusions,  and  some  delusions 
form  the  imperceptible  transition  to  the  graver  cases 
in  which  the  true  delirium  appears. 

This  consists  essentially  in  a  more  or  less  profound 
clouding  of  consciousness  associated  with  vague  delusions, 
multiple  psychosensory  disorders,  and  excitement  which 
is  at  times  very  marked. 

The  delirium  is  essentially  variable  and  mobile,  at 
times  pleasant,  at  others  painful;  the  psycho-sensory 
disturbances  are  of  the  combined  form  with  a  pre- 
dominance of  illusions  and  hallucinations  of  sight. 
The  images  and  scenes  follow  each  other  as  in  a 
dream,  of  which  they  seem  to  be  a  continuation  (dream 
delirium).  The  patient  imagines  he  is  in  the  country, 
in  the  theater,  in  a  church;  pompous  processions  march 
past  him  amidst  the  sounds  of  music  and  the  perfume 
of  flowers  and  censers;  he  converses  with  imaginary 
persons,  defends  himself  against  assassins,  rejects  a  glass 
of  milk  offered  him,  thinking  that  it  is  poison.  Often 
under  the  influence  of  his  hallucinations  he  strikes  at 
the  air  and  attempts  to  get  out  into  the  street  or  to 
pass  through  the  window,  which  he  takes  for  the  door. 


126  MANUAL  OF  PSYCHIATRY. 

However,  as  during  a  dream,  the  subject  may  by  a 
sudden  and  energetic  call  be  transported  from  the 
imaginary  world  into  the  real  one.  Such  periods  of 
lucidity  are  in  general  but  transitory. 

Often,  chiefly  in  the  beginning  of  all  forms  and 
through  the  entire  course  of  the  mild  forms,  the  delirium 
disappears  in  the  morning  to  reappear  in  the  evening 
and  to  last  during  a  portion  of  the  night. 

The  prognosis  depends  less  upon  the  intensity  of  the 
delirium  than  upon  the  physical  symptoms  which  accom- 
pany it.  As  a  rule  all  febrile  affections  complicated 
with  intense  delirium  should  be  considered  as  grave. 

In  fatal  cases  the  delirium  gradually  subsides  and 
coma  replaces  the  excitement. 

Febrile  delirium,  like  acute  alcoholic  intoxication, 
is  an  excellent  criterion  for  judging  the  resistance  of 
the  brain:  the  greater  the  predisposition  to  mental 
disorders  and  the  more  marked  the  degeneration  of  the 
subject  the  more  likely  it  is  for  delirium  to  occur 
under  such  circumstances.  Like  alcohol,  the  microbic 
poisons  and  the  toxic  products  of  the  organism  act 
most  readily  upon  brains  the  equilibrium  of  which  is 
least  stable  and  therefore  most  easily  disturbed. 

The  treatment  is  that  of  the  infectious  disease.  Strict 
watching  is  indicated.  Cold  baths  are  often  very  effica- 
cious in  relieving  the  mental  disorders. 

Infectious  delirium  proper. — Kraepelin  and  Asch- 
affenburg  have  described  under  the  name  of  infec- 
tious delirium  mental  disorders  which  supervene  in 
the  course  of  an  infection  without  the  fever  being 
particularly  intense  or  even  before  the  fever  appears 
(Initialdelirium). 


DELIRIA  OF  INFECTIOUS  ORIGIN.  127 

Infectious  delirium  is  met  with  chiefly  in  typhoid 
fever,  in  variola,  and  in  typhus  fever.  The  symptoms 
sometimes  take  the  form  of  maniacal  excitement,  more 
often  that  of  acute  confusional  insanity  or  of  hallucina- 
tory delirium. 

The  mental  disorders  of  hydrophobia. — Almost  always 
these  appear  as  the  first  symptoms  of  the  disease. 
Long  before  the  onset  of  the  hydrophobic  symptoms 
proper,  even  when  the  patient  is  unconscious  of  the 
threatening  danger,  he  becomes  depressed,  gloomy, 
seclusive,  and  has  occasional  attacks  of  anxiety.  Some- 
times, pressed  by  an  irresistible  impulse,  he  becomes 
extremely  restless,  walks  or  runs  about  for  hours  at  a 
time,  and  finally  returns  home  more  tranquil,  relieved 
for  a  time:  it  seems  that  the  morbid  irritation  of  the 
motor  zones  is  calmed.  Very  prominent  also  are  the 
inexplicable  changes  of  the  emotional  state:  the 
sudden  outbreaks  of  affection  or  of  joy,  contrasting 
strikingly  with  the  background  of  depression  and  in- 
difference. 

The  sleep  is  interrupted  by  sudden  starts  and  dis- 
turbed by  nightmares. 

The  emotional  disorders  persist  through  the  entire 
duration  of  the  disease.  But,  except  during  the  spas- 
modic seizures,  consciousness  remains  intact  up  to  the 
very  last.  In  a  few  rare  cases  a  continuous  delirium 
is  established,  assuming  various  forms:  mystic,  per- 
secutory, melancholy,  etc. 

During  the  paroxysms  there  is  very  severe  anxiety, 
agitation  reaching  almost  the  intensity  of  furor,  and 
psycho-sensory  hyperesthesia  which  in  extreme  cases 
gives  rise  to  hallucinations:    the  patient  sees  flowers. 


128  MANUAL  OF  PSYCHIATRY. 

fantastic  forms,  hears  the  noise  of  firearms,  the  sounds 
of  trumpets,  etc. 

The  phenomena  of  excitement  gradually  become  less 
marked  and  finally  disappear  with  the  onset  of  the 
paralytic  stage. 

The  diagnosis  bases  itself  upon  the  existence  of  psycho- 
sensory hyperesthesia,  and  especially  upon  the  charac- 
teristic spasms  of  hydrophobia  (pharyngeal  spasms). 

The  treatment,  which  is  but  palliative,  consists  in  the 
administration  of  antispasmodics  in  large  doses. 


CHAPTER  II. 
PSYCHOSES  OF  EXHAUSTION. 

PRIMARY  MENTAL  CONFUSION,  ACUTE  DELIRIUM. 

Well  described  by  Georget  and  by  Delasiauve  under 
the  name  of  "  stupidity,"  primary  mental  confusion 
has  only  recently  been  brought  into  prominence  again 
through  the  labors  of  Chaslin  and  of  Seglas.1 

The  fundamental  element  of  this  morbid  entity  is 
the  mental  confusion  which  is  primary,  profound,  and 
constant. 

Essential  symptoms. — After  several  days  of  ill-defined 
prodromata  such  as  headache,  anorexia,  and  change  of 
disposition,  the  disease  sets  in,  manifesting  itself  by 
psychical  and  physical  symptoms. 

A.  Psychical  symptoms. — These  are  the  symptoms  of 
intellectual  confusion,  more  or  less  marked  and  more 
or  less  pure  according  to  the  gravity  of  the  disease : 

Clouding  of  consciousness; 

Impairment  of  attention; 

Sluggish  and  disordered  associations  of  ideas; 

Insufficiency  of  perception ; 

Aboulia,  characterized  by  constant  indecision  and  by 
slowness  and  uncertainty  of  the  movements. 

1  Chaslin.  La  confusion  mentale-  primitive.  —  Seglas.  Legons 
cliniques. 

129 


130  MANUAL  OF  PSYCHIATRY. 

The  state  of  the  automatic  psychic  functions  varies 
according  to  the  form  of  the  disease :  the  mental  automa- 
tism may  be  relatively  unaffected  (simple  mental  con- 
fusion), exaggerated  (delirious  mental  confusion),  or 
paralyzed  like  the  higher  mental  functions  (mental 
confusion  of  the  stuporous  form). 

B.  Physical  symptoms. — The  physical  symptoms  are 
constant  and  "are  the  expression  of  the  general  prostra- 
tion, exhaustion,  and  ill-nourishmentv  (Seglas). 

Loss  of  flesh  is  an  early  and  a  very  marked  symptom. 
It  is  caused  by  insufficient  alimentation,  digestive  dis- 
orders, and  especially  by  a  defective  assimilation  of 
nutritive  matter. 

Fever  sometimes  exists,  chiefly  at  the  onset;  in  some 
cases,  especially  in  the  stuporous  form,  there  may  be 
subnormal  temperature. 

A  small  low  tension  pulse,  feeble  and  at  times  irregu- 
lar heart  sounds,  sluggishness  of  the  peripheral  circula- 
tion, cyanosis  of  the  extremities,  and  oedema  are  among 
the  manifestations  of  the  general  atony  of  the  cardio- 
vascular apparatus. 

The  appetite  is  abolished,  the  tongue  coated;  the 
process  of  digestion  is  accompanied  by  painful  sensa- 
tions; constipation  is  always  present. 

Frequently  there  is  a  slight  albuminuria. 

The  sleep  is  diminished,  often  replaced  by  a  dreamy 
state  analogous  to  that  of  the  infectious  diseases. 

Primary  mental  confusion  may  be  met  with  in  four 
principal  forms,  differing  in  their  gravity  and  in  the 
predominance  of  one  or  the  other  class  of  symptoms: 

Simple  mental  confusion; 

Delirious  mental  confusion; 


PSYCHOSES  OF  EXHAUSTION.  131 

Mental  confusion  of  the  stuporous  form; 

Hyperacute  mental  confusion  (acute  delirium). 

Simple  mental  confusion. — The  essential  symptoms 
which  have  been  enumerated  above  are  encountered 
here  in  their  purest  form.  The  phenomena  of  psychic 
paralysis  are  of  a  moderate  degree  of  intensity  and  the 
automatic  mental  functions  are  unaffected. 

The  patient  is  often  more  or  less  conscious  of  his  con- 
dition;   he  observes  that  a  change  has  taken  place  in 

him.    "I  am  losing  my  head. . . .  My  mind  is  a  blank " 

He  perceives  his  mental  disability  and  complains  of 
being  unable  to  gather  or  direct  his  thoughts  or  to  evoke 
reminiscences — even  those  that  have  left  a  very  strong 
impression. 

The  mental  disability  indecision,  and  insufficiency  of 
perception  bring  about  a  state  of  constant  bewilderment. 
The  patient  is  constantly  repeating  the  same  questions 
and  the  same  exclamations:  "Who  is  there?... Who 
has  come?  . . .  Who  are  you?  . . .  Everything  around  me 
has  changed. "  He  does  not  recognize  his  surroundings, 
or  if  he  does,  it  is  with  uncertainty.  He  is  not  certain 
about  the  identity  of  those  about  him;  his  bed  appears 
queer  to  him,  his  own  body  seems  to  him  to  be  changed, 
scarcely  recognizable.  In  more  advanced  degrees  we 
find  complete  disorientation,  which  is  a  constant  symp- 
tom, at  least  in  cases  of  a  certain  gravity. 

The  reactions  are  slow,  undecided;  the  movements 
awkward  and  clumsy. 

The  mental  automatism  remaining  intact,  those  men- 
tal operations  which  require  no  effort  and  no  interven- 
tion of  the  will  can  still  be  properly  performed.  Thus 
one  may  obtain  from  the  patient  a  certain  number  of 


132  MANUAL  OF  PSYCHIATRY. 

relevant  and  accurate  replies  concerning  his  age,  occu- 
pation, residence,  etc.  But  these  replies  are  always 
given  mechanically;  they  are  brief  and  abrupt,  and  can 
be  elicited  only  by  putting  the  questions  energetically 
and  concisely.  This  simple  and,  so  to  speak,  schematic 
form  of  primary  mental  confusion  is  quite  rare. 

Delirious  form. — This  form,  much  more  frequent  than 
the  preceding  one,  owes  its  peculiar  aspect  to  a  more  or 
less  marked  exaggeration  of  the  activity  of  the  mental 
automatism,  which  gives  rise  to :  (a)  flight  of  ideas  and 
incoherence;  (6)  delusions  and  psycho-sensory  disorders; 
(c)  more  or  less  excitement. 

The  delusions  present  no  systematization,  as  for  this 
at  least  a  relative  lucidity  is  necessary.  They  assume 
different  forms,  which  often  interchange  in  the  same 
subject;  ideas  of  grandeur,  transformation  of  the  per- 
sonality: melancholy  ideas,  ideas  of  persecution.  Pain- 
ful delusions  are  the  most  common.  Sometimes  the 
ideas  are  absurd,  like  those  of  senile  dements  or  of  gen- 
eral paretics. 

The  psycho-sensory  disorders  consist  sometimes  in 
agreeable  but  more  often  in  painful  illusions  and  hallu- 
cinations of  all  the  senses,  though  most  usually  of  vision 
and  of  hearing.  They  may  combine  so  as  to  create  an 
imaginary  world  which  is  essentially  mobile  and  change- 
able, or,  on  the  contrary,  they  may  coexist  without  any 
apparent  correlation. 

Occasionally  the  incessant  illusions  and  hallucina- 
tions impart  to  the  patient  a  peculiar  expression.  Most 
cases  described  under  the  name  of  hallucinatory  delir- 
ium should  properly  be  included  in  this  form  of  mental 
confusion. 


PSYCHOSES  OF   EXHAUSTION.  133 

The  emotional  tone  is  variable,  governed  to  some  extent 
by  the  delusions.  However,  one  often  finds,  in  spite  of 
very  active  delirium,  a  striking  indifference,  so  that  a 
certain  discord  exists  between  the  delusions  and  the 
emotions. 

The  agitation  is  not  always  due  to  the  delusions  and 
psycho-sensory  disturbances.  As  in  dementia  precox, 
so  also  in  this  condition  the  patient  may  give  vent  to 
cries  and  motor  discharges  that  are  purety  automatic  and 
without  any  apparent  purpose. 

Mental  confusion  of  the  stuporous  form. — Here  the 
psychic  paralysis  involves  not  only  the  higher  mental 
faculties,  but  also  the  automatic  psychic  functions. 

The  limbs  are  motionless,  the  eyes  dull,  and  the  face 
expressionless;  the  mouth  may  be  half  open  and  the 
saliva  dribbling  away  uncontrolled.  The  patient  fails 
to  react  even  to  the  strongest  stimulation,  or  he  may 
react  but  very  feebly. 

Cataleptic  attitudes  with  dilated  pupils  are  quite  often 
seen. 

Hyperacute  form  (acute  delirium). — This  form  is  char- 
acterized by  the  intensity  of  the  delirium  and  of  the 
agitation  on  the  one  hand,  and  by  the  gravity  of  the 
general  symptoms  on  the  other  hand. 

The  patient,  attacked  by  numerous  hallucinations, 
either  painful  or  agreeable  and  accompanied  by  erotic 
tendencies,  becomes  completely  disoriented  and  wildly 
excited:  he  shouts,  sings,  jumps  out  of  bed,  strikes  the 
walls,  and  attacks  those  about  him.  The  eyes  are  in- 
jected, the  respiration  panting,  the  skin  covered  with 
perspiration,  the  temperature  elevated,  and  the  pulse  is 
small  and  often  rapid  and  irregular.    These  signs  point 


134  MANUAL  OF  PSYCHIATRY. 

to  the  gravity  of  the  condition.  In  fatal  cases  the 
patient  rapidly  passes  into  coma  and  dies  in  a  few  days. 
In  favorable  > cases  the  agitation  gradually  disappears, 
the  patient  regains  his  sleep,  and  recovery  finally  takes 
place;  this  favorable  termination  is  rare. 

Duration,  course,  and  prognosis  of  primary  mental 
confusion. — The  duration  of  the  attack  varies  from  sev- 
eral days  to  a  few  months.  The  curve  representing  its 
intensity  is  rapidly  ascendant,  then  it  remains  stationary 
for  some  time  without  oscillations,  and  finally  descends 
gradually.  The  period  of  descent  often  presents  irreg- 
ularities on  account  of  recrudescences  of  the  disease, 
which  are  usually  mild. 

Such  is  the  course  of  favorable  cases,  which  fortu- 
nately are  the  most  frequent  (excluding  acute  delirium) . 
Recovery  is  complete.  But  the  patient's  recollection  of 
the  events  which  have  taken  place  during  the  illness  is 
vague  or  even  absent.  The  period  of  convalescence  is 
very  protracted. 

Suicide  is  rare  even  in  the  depressed  forms;  the 
aboulia  is  the  patient's  safeguard. 

In  unfavorable  cases  death  occurs  from  collapse  in 
the  hyperacute  form,  and  from  cachexia  or  from  some 
complication  (pneumonia,  subacute  tuberculosis,  in- 
fluenza,  infections  following  traumatisms)  in  the  less 
rapid  cases. 

Diagnosis. — The  principal  elements  of  diagnosis  are: 
the  appearance  on  mental  confusion  at  the  onset  of  the 
disease;  the  possibility  of  obtaining  correct  replies  to 
simple  and  energeticalfy  put  questions;  the  state  of 
physical  exhaustion,  and  the  existence  of  the  special 
etiological  factors,  which  we  shall  mention  further  on. 


PSYCHOSES  OF  EXHAUSTION.  135 

Many  other  psychoses  may  resemble  primary  mental 
confusion  because  they  may  be  complicated  by  secondary 
mental  confusion.  The  points  of  differential  diagnosis 
will  be  indicated  in  the  respective  chapters  devoted 
to  the  consideration  of  these  psychoses. 

Pathological  anatomy.  —  The  lesions  of  primary 
mental  confusion  are  of  two  kinds:  inflammatory  and 
degenerative.  The  former,  wThich  are  most  prominent  in 
the  severe  cases,  consist  in  congestion  and  diapedesis 
in  the  nervous  centers.  The  latter  are  more  constant, 
and  consist  in  degeneration  of  the  nerve-cells,  which 
is  demonstrable  by  Nissl's  method.1 

Etiology. — All  factors  capable  of  bringing  about  a 
rapid  and  profound  exhaustion  of  the  organism  occur 
in  the  etiology  of  primary  mental  confusion:  physical 
and  mental  stress,  painful  and  prolonged  emotions, 
but  especially  grave  somatic  affections.  The  puerperal 
state,  through  the  exhaustion  which  it  entails  as  well 
as  through  the  nutritive  disorders  and  infections  by 
which  it  is  sometimes  complicated;  the  infectious 
diseases  (typhoid  fever,  the  eruptive  fevers,  influenza, 
cholera);  profuse  hemorrhages;  inanition,  etc.,  are' 
among  the  causes  frequently  found  in  the  history  of 
the  disease. 

How  is  the  action  of  these  factors  to  be  explained? 
Two  hypotheses  are  possible. 

According  to  the  one,  that  of  Binswanger,  the  general 


1  Ballet  et  Faure.  Contribution  a  Vanatomie  pathologique  de  lo 
psychose  polynevritique  et  certaines  formes  de  confusion  mentale 
primitive.  Presse  med.,  Nov.  30,  1898. — Maurice  Faure.  Sur 
les  lesions  cellulaires  corticales  observees  dans  six  cas  de  troubles 
mentaux  toxi-infectieux.     Rev.  neurol.,  Dec.  1899. 


136  MANUAL  OF  PSYCHIATRY. 

exhaustion  of  the  organism  brings  about  a  deficient 
cerebral  nutrition  the  clinical  expression  of  which  is 
primary  mental  confusion. 

According  to  the  other,  advanced  by  Kraepelin, 
the  causes  enumerated  above  bring  about  disturbances 
in  the  nutritive  changes  and  determine  the  production 
of  toxic  substances  which,  acting  upon  the  cerebral 
cells,  give  rise  to  an  intoxication  psychosis:  primary 
mental  confusion. 

Perhaps  both  causes  are  at  work  simultaneously.  In 
either  case  exhaustion  constitutes  the  essential  cause 
of  the  affection  and  the  term  "Exhaustion  Psychosis'' 
is  therefore  perfectly  applicable  to  it. 

Treatment. — During  the  entire  acute  period  of  the 
disease  rest  in  bed  should  be  rigorously  enforced. 

Proper  alimentation  is  of  great  importance.  A  re- 
constructive diet  better  than  all  medication  sustains 
the  patient's  strength  and  even  calms  the  agitation. 
Milk,  eggs,  chopped  meat,  and  meat-juice  should  form 
the  basis  of  the  diet. 

In  cases  of  sitiophobia  one  must  resort  without 
hesitation  to  artificial  feeding;  these  patients  cannot 
with  impunity  be  allowed  to  fast. 

Injections  of  artificial  serum  are  of  great  service  and 
of  easy  application.  The  necessary  apparatus  consists 
chiefly  of  a  glass  funnel,  a  soft-rubber  tube,  and  a 
slender  trochar. 

Ordinarily  300-500  grams  of  Hay  em's  serum  may  be 
injected  every  day  or  every  second  day. 

The  most  important  results  of  this  treatment  are  the 
rising  of  the  blood  pressure  and  the  diuresis.1 

1  Cullerre.     De    la    transfusion    sereuse     soua-cutanee     dans     les 


PSYCHOSES  OF  EXHAUSTION.  137 

Moderate  physical  exercise,  life  in  the  open  air,  read- 
ing, and  light  and  brief  mental  work  accelerate  the 
course  of  convalescence.1 


psychoses  aigues  avec  auto-intoxication.  Prog,  med.,  Sept.  30,  1899. 
— Jacquin.  Du  serum  artificiel  en  Psychiatric  Ann.  med.  psych., 
May-June,   1900. 

1  We  have  intentionally  omitted  the  mental  disorders  of  chronic 
exhaustion.  They  form  a  part  of  the  symptomatology  of  neuras- 
thenia, for  a  description  of  which  the  reader  is  referred  to  works  on 
neurology. 


CHAPTER  III. 

PATHOLOGICAL  DRUNKENNESS. 

(acute  alcoholic  intoxication). 

The  term  drunkenness  is  here  used  to  designate  the 
nervous  and  mental  symptoms  by  which  acute  alcoholic 
intoxication  manifests  itself. 

The  predisposition  to  the  state  of  drunkenness,  quite 
variable  in  different  subjects,  is  a  part  of  the  general 
tendency  of  the  individual  toward  nervous  and  mental 
disorders.  "It  may  be  truly  said  that  alcohol  is  the 
touchstone  of  the  equilibrium  of  the  cerebral  functions."1 

Drunkenness  is  somewhat  schematically  divided  into 
two  stages:  (1)  excitement,  and  (2)  paralysis.  In  re- 
ality paralysis  is  present  from  the  begininng,  but  in 
the  first  stage  it  is  limited  to  the  highest  psychic  func- 
tions and  is  masked  by  the  intensity  of  the  automatic 
phenomena,  so  that  it  does  not  become  evident  until 
the  second  stage,  when  all  the  nervous  and  mental 
functions  become  involved  in  the  paralysis. 

First  Stage :  Excitement. — Psychic  inhibition,  the  first 
manifestation  of  the  paralysis,  is  seen  in  the  slow 
association  of  ideas,  the  distraction,  and  the  insuffi- 
ciency of  perception.  The  automatism  is  apparent 
from  the   disconnected  conversation,  which  may  show 


1  F6r6  La  Famille  nevropathique.  Paris.  F.  Alcan. 

138 


PATHOLOGICAL  DRUNKENNESS.  139 

a  true  flight  of  ideas,  the  abnormal  pressure  of 
activity,  the  more  or  less  marked  morbid  euphoria  and 
irritability,  the  impulsive  character  of  the  reactions, 
and  the  extremely  voluble  speech.  The  moral  sense 
and  the  regard  for  common  conventionalities  gradu- 
ally disappear,  and  the  patient  may  commit  ridiculous, 
repugnant,  offensive,  or  even  criminal  acts. 

Second  Stage:  Paralysis. — Paralysis,  confined  in  the 
preceding  stage  to  the  sphere  of  the  higher  psychic 
functions,  now  attacks  the  automatic  functions.  The 
movements  are  awkward  and  clumsy,  the  speech  indis- 
tinct, and  the  gait  unsteady.  Gradually  the  patient 
falls  into  a  profound,  sometimes  comatose,  sleep, — the 
final  stage  of  the  attack, — from  which  he  awakes  lucid 
but  with  a  confused  recollection  of  what  has  passed 
and  with  a  pronounced  sensation  of  mental  and  physical 
fatigue. 

Such  is,  rapidly  sketched,  the  aspect  of  common 
drunkenness.  From  the  accentuation  or  obliteration  of 
certain  features  result  the  diverse  abnormal  or  patho- 
logical forms. 

Comatose  drunkenness. — The  phenomena  of  excite- 
ment are  either  absent  or  very  transient.  From  the 
beginning  the  paralysis  affects  the  entire  brain.  The 
patient  sinks  and  remains  inert  and  insensible  for 
several  hours.  His  face  is  congested.  Gradually  the 
comatose  state  is  replaced  by  sleep,  from  which  the 
patient  awakes  without  any  recollection  whatever  of 
the  occurrences  immediately  preceding  his  intoxica- 
tion. Sometimes  the  pulse  becomes  small,  the  heart 
weak,  the  breathing  labored,  and  in  some  cases,  which 
are  fortunately  rare,  the  patient  dies  in  collapse. 


140  MANUAL  OF  PSYCHIATRY. 

Maniacal  drunkenness. — Here  the  paralysis  occupies 
a  secondary  position  and  the  excitement  dominates  the 
scene.  The  phenomena  of  agitation  generally  develop 
very  rapidlv.  All  of  a  sudden  the  drunkard,  while  yet 
at  the  saloon-keeper's  bar,  is  seized  with  an  outbreak 
of  furious  madness  without  any  apparent  cause  or 
provocation;  he  breaks  objects  and  furniture,  becomes 
noisy,  and  threatens  and  attacks  those  about  him. 
The  extreme  clouding  of  the  intellect  shows  that,  in  spite 
of  appearances,  "psychic  activity  takes  but  a  very 
small  part  in  the  production  of  the  outbreak/'  and 
that  "  subjugated  by  this  automatic  development  of 
psycho-motor  activity  it  disappears  entirely."  1  Almost 
always  numerous  psycho-sensory  disorders  (hallucina- 
tions and  illusions)  are  associated  with  the  clouding 
of  the  intellect  and  the  excitement. 

The  attack  terminates  in  profound  sleep-  This,  as 
in  the  preceding  form,  is  followed  by  an  almost  com- 
plete amnesia. 

Convulsive  drunkenness.  —  The  maniacal  form  of 
drunkenness  resembles  closely  the  delirious  attacks  of 
epilepsy.  The  relation  between  epilepsy  and  acute 
alcoholic  intoxication  is  rendered  still  more  apparent 
by  the  fact  that  drunkenness  may  clinically  assume 
the  aspect  of  an  epileptic  seizure.  This  is  explained 
by  the  convulsive  properties  of  alcohol,  which  have 
been  demonstrated  experimentally.  Attacks  precisely 
like  those  of  essential  epilepsy  may  supervene  in  the 
course  of  common  drunkenness.  In  all  cases  they 
immediately  follow  the  alcoholic  excesses,  differing  in 


1  Gamier.     La  folie  a  Paris. 


PATHOLOGICAL  DRUNKENNESS.  141 

this  respect  from  those  epileptiform  seizures  which 
supervene  in  the  course  of  chronic  alcoholism. 

Delusional  drunkenness. — This  curious  but  rare  form 
has  been  well  studied  by  Gamier.  The  delusions  are 
extremely  variable:  ideas  of  persecution,  ambitious 
ideas,  depressive  ideas  with  suicidal  tendencies,  etc. 
Delusional  drunkenness  is  encountered  only  in  pro- 
foundly degenerated  individuals. 

Treatment. — This  of  course  varies  with  the  different 
forms.  Maniacal  or  delusional  drunkenness  requires 
strict  watching  and  immediate  isolation;  the  comatose 
form  requires  the  use  of  external  and  internal  stimu- 
lation (friction,  ammonium,  ether,  caffein). 


CHAPTER  IV. 

CHRONIC  ALCOHOLISM. 

Chronic  alcoholism  manifests  itself:  (1)  in  per- 
manent symptoms  (the  chronic  stigmata  of  alcoholism), 
and  (2)  in  episodic  accidents. 

I.  Permanent  Symptoms. 
The  permanent  symptoms  are  psychical  and  physical. 

A.    PSYCHICAL   SYMPTOMS. 

There  is  an  enfeeblement  of  all  the  psychic  functions. 

Intellectual  sphere. — Intellectual  activity  and  the  ca- 
pacity for  work  are  diminished.  The  patient  becomes 
dull,  negligent,  and  clumsy. 

The  disorders  of  memory  consist  in  a  definite  retro- 
grade amnesia  by  destruction  of  impressions,  associated 
with  a  more  or  less  marked  anterograde  amnesia.  The 
former  follows  the  general  law  of  amnesia.  Its  course 
is  slowly  progressive;  but  it  is  rare  for  it  to  reach  as 
complete  a  development  as  it  does  in  general  paresis. 
The  anterograde  amnesia  renders  it  difficult  or  even 
impossible  for  the  patient  to  acquire  new  impressions; 
thus  the  stock  of  ideas  becomes  more  and  more  impover- 
ished. 

142 


CHRONIC  ALCOHOLISM.  143 

The  judgment  is  constantly  affected:  the  patient 
realizes  but  imperfectly  his  condition  and  the  importance 
and  significance  of  his  actions. 

Emotional  sphere. — As  in  most  affections  with  a 
basis  of  intellectual  enfeeblement,  we  find  in  chronic 
alcoholism  indifference  associated  with  morbid  irrita- 
bility. 

The  chronic  alcoholic  is  not  at  all  concerned  with 
his  ruined  business,  the  misery  of  his  family,  or  the 
compromise  of  his  honor.  Only  the  desire  for  alcohol 
can  still  arouse  him  from  his  mental  torpor.  The 
atrophy  of  the  moral  sense,  which  in  these  cases  goes 
hand  in  hand  with  the  general  indifference,  is  such  that 
in  order  to  procure  his  favorite  drinks  the  patient  does 
not  hesitate  to  make  use  of  the  most  unscrupulous  means 
and  to  associate  with  the  vilest  characters.  If  he  still 
works,  he  spends  his  entire  salary  for  drink.  If  he 
does  not  work,  as  is  the  rule  in  such  cases,  he  accumu- 
lates debts  in  the  lowest  of  drinking- dens,  extorts  from 
his  relatives  what  little  money  they  may  have  earned 
by  hard  labor,  and  he  may  even  resort  to  stealing. 

The  irritability  and  the  impulsive  tendencies  give  rise 
to  violent,  terrible  outbursts  of  anger,  and  often  to 
assaults  and  attempts  at  murder. 

Delusions  may  appear  at  times,  almost  always  those 
of  persecution  or  of  morbid  jealousy.  When  they 
become  more  developed  and  acquire  a  certain  fixedness 
they  constitute  the  alcoholic  systematized  delirium 
which  we  shall  study  later  on. 

Still  the  patient's  obscure  consciousness  presents 
at  times  a  temporary  lucidity.  Strong  remonstrances 
of  friends   or   grave    disorders  of    the   general  health 


144  MANUAL  OF  PSYCHIATRY. 

may  give  birth  to  repentance.  The  unhappy  subject 
regrets  his  excesses,  declares  himself  a  great  sinner, 
swears  by  all  that  is  holy  that  he  will  not  take  another 
drop  of  wine  or  liquor,  and  announces  his  intention  to 
join  a  temperance  association.  These  good  resolutions 
are  carried  out  for  several  days,  weeks,  or  even  months ; 
but  almost  always  the  patient  falls  again:  his  feeble 
will  gives  way  and  he  can  struggle  no  longer.  He  is 
in  a  vicious  circle:  "he  drinks  because  his  will  is  weak, 
and  his  will  is  weak  because  he  drinks. 

When  they  attain  a  certain  degree  of  intensity,  the 
mental  disorders  which  I  have  sketched  constitute 
alcoholic  dementia. 

Alcoholic  dementia  is  slowly  progressive.  It  takes 
years  to  become  fully  established.  Moreover, — and 
this  is  a  highly  important  feature, — it  ceases  to  progress 
with  the  cessation  of  the  alcoholic  excesses. 

B.    PHYSICAL    SYMPTOMS. 

The  sleep  is  diminished,  restless,  disturbed  by  un- 
pleasant dreams.  The  patient  is  apt  to  dream  that  he 
is  at  his  occupation  (occupation-dreams);  the  work  is 
pressing,  but  in  spite  of  his  diligence  he  is  always  behind 
and  the  results  are  unsatisfactory.  At  other  times  ver- 
itable dramas  are  enacted:  assassins  pursue  him,  rats 
run  at  him,  snakes  and  monstrous  spiders  creep  over  him 
(zoopsia).  These  dreams  present  all  the  characteristics 
of  delirium  tremens,  which  has  been  aptly  called  a  pro- 
longed dream.  Sometimes  the  patient  wakes  up  in  the 
midst  of  his  nightmare  with  his  head  heavy,  the  body 
covered  with  perspiration,  still  doubting  the  inanity  of 
his  terrors. 


CHRONIC  ALCOHOLISM.  145 

Attacks  of  vertigo  and  flashes  of  light,  which  often 
precede  and  usher  in  apoplectiform  attacks,  occur  as 
the  result  of  the  disordered  condition  of  the  cerebral 
circulation. 

The  motor  disturbances  consist  in  muscular  weakness, 
chiefly  marked  in  the  lower  extremities,  a  tendency  to 
lassitude,  and  a  constant  tremor  affecting  especially 
the  tongue  and  the  hands ;  the  digital  tremor  is  rendered 
very  apparent  when  the  patient  holds  out  his  hand  and 
slightly  spreads  out  his  fingers:  it  is  a  fine,  horizontal 
tremor,  not  very  rapid. 

The  tendon  reflexes  are  sometimes  exaggerated,  but 
much  more  frequently  diminished  or  abolished ;  the  cuta- 
neous reflexes  are  usually  exaggerated  (plantar  reflex), 
especially  in  intoxications  by  the  essences  (absinthe) ; 
sometimes  they  are  abolished;  the  pupils  are  paretic 
and  sometimes  slightly  myotic.  Occasionally  there  is  a 
slight  degree  of  strabismus  or  of  ptosis.  The  vision 
is  frequently  disordered,  due  to  retrobulbar  neuritis; 
there  is  diminution  of  the  acuteness  and  there  may  be 
a  "central  scotoma  having  the  shape  of  an  ellipse  the 
long  axis  of  which  is  horizontal"  (Babinski). 

Cutaneous  sensibility  is  reduced  in  the  large  majority 
of  cases;  the  hypoaBsthesia  is  often  unilateral;  in  such 
cases  it  is  associated  with  other  hysteroid  manifesta- 
tions: hysterogenic  zones,  globus  hystericus,  absence 
of  the  pharyngeal  reflex. 

Among  the  disorders  of  deep  sensibility  are  to  be  noted 
numbness,  tingling,  hypersesthesias  of  portions  of 
muscles  which  are  painful  on  pressure  or  are  cramped; 
dull  pains  with  lancinating  paroxyms  resembling  the 
lightning  pains  of  tabes. 


146  MANUAL  OF  PSYCHIATRY. 

The  motor  and  sensory  disturbances,  whatever  their 
distribution  may  be,  are  always,  due  to  peripheral  poly- 
neuritis which  is  a  constant  manifestation  of  chronic 
alcoholism. 

The  gastro-intestinal  disorders  are  manifested  b}^  ano- 
rexia, pyrosis,  coated  tongue  in  the  morning,  slow  and 
painful  digestion,  and  constipation. 

The  liver  is  often  enlarged,  and  so  is  also  the  spleen. 
The  true  alcoholic  cirrhosis  is  sometimes  met  with,  but 
assumes  a  special  aspect,  the  principal  peculiarity  of 
which  is  the  absence  of  ascites. 

Diagnosis. — Chronic  alcoholism  is  to  be  differentiated 
chiefly  from  those  diseases  in  which  there  is  intellectual 
enfeeblement.  The  question  of  differential  diagnosis  will 
be  considered  in  connection  with  each  of  these :  general 
paresis,  senile  dementia,  and  dementia  prsecox. 

Prognosis. — This  is  always  grave.  The  symptoms  of 
intellectual  enfeeblement  once  established  are  not  likely 
to  become  abated.  The  timely  suppression  of  alcohol 
prevents  their  appearance  or,  if  they  are  already  present, 
arrests  their  progressive  course.  Unfortunately  this  is 
very  difficult  to  accomplish. 

Pathological  anatomy. — The  arterial  system  is  the 
seat  of  atheromatous  degeneration  the  intensity  and 
extent  of  which  are  variable;  it  affects  especially  the 
arteries  of  the  cerebrum.  Atheromatous  changes  in  the 
arteries  at  the  base  are  frequent,  though  not  constant. 
The  arterioles  and  capillaries  always  present  a  state  of 
degeneration  characterized  by  the  presence  of  granular 
masses  containing  nuclei,  which  indicate  their  cellular 
origin. 

The  nerve-cells  undergo  " r  a  certain  degree  of  granulo- 


CHRONIC  ALCOHOLISM.  147 

pigmentary  and  fatty  degeneration."  1  The  nerve- 
fibers,  especially  the  tangential  and  commissural  fibers, 
are  partially  atrophied. 

The  extent  of  the  lesions  in  the  nervous  elements  is 
proportionate  to  that  of  the  intellectual  enfeeblement. 
Therefore  it  is  especially  marked  in  cases  of  advanced 
dementia. 

The  organs  of  the  vegetative  functions  present  the 
usual  lesions  of  alcoholism:  myocarditis,  interstitial 
nephritis,  alcoholic  gastritis,  fatty  degeneration  of  the 
liver.  The  hepatic  lesions  have  become  of  special  in- 
terest since  Klippel  has  shown  that  they  are  the  imme- 
diate cause  of  certain  deliria  occurring  in  alcoholics. 

Etiology.  —  How  does  one  become  an  alcoholic? 
This  question  resolves  itself  into  two  distinct  inquiries, 
as  follows : 

1.  Why  does  a  given  individual  drink  alcohol  in 
injurious  doses? 

2.  Why  are  certain  nervous  systems  more  susceptible 
than  others  to  the  poisonous  action  of  alcohol? 

It  would  require  a  volume  to  reply  fully  to  the  first 
question;  indeed,  it  would  mean  a  solution  of  the 
gigantic  problem  of  alcoholism  in  its  social  relations. 
According  to  Kraepelin,  heredity  seems  to  play  a  cer- 
tain role.  The  tendency  to  alcoholic  excesses  is  trans- 
mitted to  descendants.  Fere  also  states  that  "to  be- 
come an  alcoholic  one  must  be  alcoholizable ;  the  mere 
indulgence  in  fermented  beverages  is  not  in  itself  suffi- 
cient." This  factor  is  of  some  importance,  though 
slight   when   compared   to   that   of   the   social  factors. 

1  Klippel.     Du  delire  alcoolique.     Mercredi  medical,  Oct.   1893. 


148  MANUAL  OF  PSYCHIATRY. 

Among  the  latter  the  most  powerful  is  undoubtedly 
the  ignorance  of  the  people  as  to  the  true  action  of 
alcohol,  as  well  as  the  false,  disastrous  notion  prevailing 
among  all  classes  of  society  that  alcohol  gives  force 
and  is  therefore  indispensable  to  the  workingman  for 
the  performance  of  hard  labor.  Though  it  is  to-day  a 
well-established  fact  in  the  medical  and  scientific  world 
that  alcohol  produces  but  an  illusion  of  force,  and  that 
the  sense  of  increased  energy  which  it  gives  is  but  a 
morbid  subjective  phenomenon,  this  idea  is  still  looked 
upon  by  the  public  as  an  innovation  of  doubtful  cer- 
tainty, "an  invention  of  the  doctors.'/ 

To  ignorance  is  joined  the  element  of  suggestion. 
There  can  be  no  doubt  that  many  individuals  begin  to 
drink  by  chance  or  by  example.  For  a  laborer  it  is 
almost  impossible  in  his  social  intercourse  to  escape 
alcoholism,  even  though  he  may  be  aware  of  its  dangers. 
His  comrades  drag  him  into  the  saloons,  which  constitute 
perpetual  temptations  on  his  way.  Refusal  to  accept 
their  invitations  exposes  him  to  their  ridicule  and  to 
their  ill-treatment,  and  condemns  him  to  the  isolation 
of  a  social  outcast;  here,  as  everywhere  else,  uto  do  as 
others  do"  is  the  great  principle  that  governs  the  indi- 
vidual and  obliges  him  to  conduct  himself  against  his 
own  interest  and  even  against  his  own  inclinations. 

Among  the  social  factors  there  are  a  great  many 
special  factors  one  of  which  deserves  special  mention, 
namely,  grief.  Some  alcoholics  abandon  themselves 
to  drink  on  account  of  financial  ruin,  others  because 
of  domestic  unhappiness,  etc.  However,  it  is  to  be 
remembered  that  quite  often  patients  claim  their 
misfortunes    to   have  been  the  cause   of  their  intern- 


CHRONIC  ALCOHOLISM.  1  19 

perance,  while  in  reality  they  are  the  effect.  The 
drunkard  pretends  that  he  drinks  to  find  relief  from 
his  domestic  griefs,  while  in  fact  his  intemperance 
has  caused  them. 

We  now  have  to  answer  the  second  question:  Why 
does  alcohol  exert  a  rapid  and  intense  action  upon 
certain  nervous  systems,  while  others  resist  success- 
fully much  greater  excesses? — It  is  here  that  the  indi- 
vidual predisposition  comes  into  play. 

Like  the  symptoms  of  acute  alcoholism,  those  of 
chronic  alcoholism  appear  chiefly  in  predisposed  individ- 
uals; and  the  greater  the  predisposition  the  more 
rapidly  do  these  symptoms  develop.  We  see  daily 
in  general  hospitals  patients  presenting  atheroma  of 
the  arterial  system,  alcoholic  cirrhosis,  etc.,  and  show- 
ing but  slight  if  any  nervous  or  mental  disorders ;  while 
in  insane  asylums  patients  are  admitted  whose  alcoholic 
excesses  have  been  relatively  slight  and  whose  nervous 
systems  have  nevertheless  already  suffered  irreparable 
damage.  The  quality  of  the  soil  is  therefore  of  pri- 
mary importance. 

The  pathogenic  action  of  alcohol  is  also  favored  by 
all  the  factors  which  diminish  the  resistance  of  the 
organism,  such  as  stress,  grief,  want  of  sleep,  and  acute 
or  chronic  infectious  diseases  (tuberculosis).  Thus 
we  often  encounter,  associated  in  the  same  subject, 
the  abuse  of  alcohol,  predisposition,  and  debilitating 
influences. 

It  would  be  useful  to  know  which  among  the  alcoholic 
beverages  produce  so  great  a  toxic  action  as  to  be 
particularly  responsible  for  the  production  of  alcoholism. 
Clinical   evidence   seems   to   show   that   the  principal 


150  Manual  of  psychiatry. 

factor  in  alcoholism  is  the  quantity  and  not  the  quality 
of  the  beverage  ingested.  The  experiments  of  Joffroy 
and  Serveaux  have  shown  clearly  that  alcoholic  intoxi- 
cation is  due  to  ethyl  alcohol  itself,  and  not  to  the 
impurities  often  associated  with  it.  Therefore  all 
fermented  beverages  may  cause  alcoholism:  liquors, 
alcoholic  tonics,  wines,  beers,  ciders,  the  alcohol  of 
wines  as  well  as  that  of  substances  used  in  the  indus- 
tries. However,  "a  given  quantity  of  alcohol  is  the 
more  toxic  the  more  concentrated  it  is;  for  this  reason 
the  stronger  alcoholic  beverages  play  a  prominent 
role  in  the  production  af  alcoholism/'  1 

The  essences,  particularly  the  essence  of  absinthe, 
have  been  claimed  to  be  especially  prone  to  produce 
alcoholic  epilepsy.  This  opinion,  based  chiefly  upon 
experiments,  has  not  been  altogether  confirmed  clin- 
ically. 

Treatment. — The  most  important  indication  in  the 
treatment  is  complete  abstinence  from  alcohol  in  any 
form.  This  in  well-established  cases  of  chronic  alco- 
holism can  be  carried  out  only  in  an  insane-asylum 
or,  still  better,  in  a  special  institution  for  inebriates.2 


1  Antheaume.  De  la  toxicite  des  alcools.  These  de  Paris,  F.  Alcan 
1897.  This  work  contains  the  results  of  the  experiments  of  Joffroy 
and  Serveaux. 

2  Serieux.  Les  etablissements  pour  le  traitement  des  buveurs 
en  Anghterre  et  aux  Etats-Unis.  Projets  de  creation  d'asiles 
d'alcooliques  en  Autriche  et  en  France.  Bullet,  de  la  soc.  de  med. 
ment.  de  Belg.,  1895. — By  the  same  author.  L' assistance  des 
alcooliques  en  Suisse  et  en  Allemagne.  Ibid.  Also  L'Asile 
d'alcooliques  de  departement  de  la  Seine.  Ann.  med.  psych.,  1895, 
Nov.-Dec 


CHRONIC  ALCOHOLISM.  151 

II.  Episodic  Accidents. 

The  episodic  accidents  of  chronic  alcoholism  may  be 
acute  or  subacute,  and  are  of  four  kinds:  delirium 
tremens,  alcoholic  systematized  delirium,  the  poly- 
neuritic psychosis,  and  alcoholic  epilepsy. 

The  polyneuritic  psychosis  is  to  be  studied  later  on; 
the  symptoms  of  this  disease  are  the  same  whether  it 
results  from  an   infection,   from  an   autointoxication 
or  from  the  abuse  of  alcohol. 

Alcoholic  epilepsy  presents  the  same  clinical  features 
as  essential  epilepsy.  The  convulsions  often  follow 
alcoholic  excesses,  from  which  they  are  separated  by 
an  interval  of  twenty-four  hours  and  sometimes  longer. 
They  may  also  be  associated  with  acute  intoxication, 
so  that  they  are  dependent  at  once  upon  alcoholic 
epilepsy  proper  and  upon  the  acute  intoxication.  The 
prognosis  is  variable.  Though  the  convulsions  usually 
disappear  with  the  suppression  of  alcohol,  still  in  many 
cases  they  persist  and  the  subject  behaves  like  an  or- 
dinary epileptic.  Alcoholic  intoxication  thus  resembles 
in  its  after  effects  certain  infectious  diseases,1  notably  ty- 
phoid fever,  which  are  apt  to  leave  epilepsy  as  a  sequel. 

Analogous  to  the  states  of  obscuration  and  the 
absences  of  epilepsy  are  the  states  of  transient  sub- 
consciousness which  are  occasionally  met  with  in 
alcoholics,  and  in  the  course  of  which  the  patients  may 
commit  criminal  acts.2 

1  Dide.  Valeur  de  la  fievre  typhoide  dans  Vetiologie  de  I'epilepsie. 
Revue  de  medecine,  Feb.   1899. 

2  Moeli.  Ueber  die  vorubergehenden  Zustcinde  abnormen  Bewusst- 
seins  in  Folge  von  Alkoholvergiftung  und  deren  forensische  Be- 
deutung.     Allgem.  Zeitsch.  fur  Psychiat.,  Nos.  2  and  3,  1900. 


152  MANUAL  OF  PSYCHIATRY. 

Of  delirium  tremens  and  of  alcoholic  systematized 
delirium  we  shall  make  a  more  detailed  study. 

A.    DELIRIUM   TREMENS. 

The  prodromata  consist  in  an  accentuation  of  the 
symptoms  of  alcoholism.  The  sleep  is  more  than  ever 
disturbed  by  nightmares,  preceded  by  painful  h}Tpna- 
gogic  hallucinations,  and  reduced  in  the  last  days  before 
the  attack  to  a  vague  somnolence.  Violent  headaches 
and  a  sort  of  inexplicable  uneasiness  usher  in  a  grave 
affection.  Frequently  the  patient,  divining  the  cause 
of  the  threatening  storm,  suppresses  the  alcohol;  in 
vain,  however,  for  the  attack  almost  alwa}^s  breaks  out 
in  spite  of  the  tardy  abstinence. 

Psychic  symptoms. — These  were  admirably  analyzed 
years  ago  by  Lasegue  and  more  recentty  by  Wernicke. 
Three  chief  symptoms  dominate  the  scene:  disorder  of 
consciousness,  hallucinatory  delirium,  and  motor  agi- 
tation. 

The  disorder  of  consciousness  involves  exclusively  the 
notion  of  the  external  world,  i.e.,  the  allopsychic  orien- 
tation, leaving  intact  the  notion  of  the  personality, 
i.e.,  the  autopsy  chic  orientation  (Wernicke). 

The  illusions  and  hallucinations  are  constant  and  at 
times  incessant.  They  present  two  general  character- 
istics: (1)  they  are  painful;  (2)  they  are  combined  in 
such  a  manner  as  to  form  complete  scenes  and  create 
around  the  patient  a  whole  imaginary  and  often  fan- 
tastic world.  They  affect  all  the  senses,  but  especially 
the  sense  of  sight. 

The  visions  of  delirium  tremens  are  always  mobile 


CHRONIC  ALCOHOLISM.  153 

and  animated.     They  form  an  uninterrupted  succession 
of  strange,  painful,  or  terrifying  scenes. 

Two  principal  forms  of  the  delirium  may  be  distin- 
guished: (a)  occupation  delirium,  and  (b)  persecutory 
delirium. 

(a)  Occupation  delirium. — The  patient  thinks  that  he 
is  amongst  familiar  surroundings  and  imagines  himself  at 
his  usual  occupation.  The  hallucinations  possess  re- 
markable distinctness  and  intensity:  the  cab  driver 
leads  his  horses,  urges  them  on,  whips  them,  and  runs 
over  pedestrians  who  do  not  get  out  of  his  way  quickly; 
the  cafe  waiter  waits  upon  his  clients,  receives  the 
money,  and  shows  them  to  vacant  seats. 

(b)  Persecutory  delirium. — The  psycho-sensory  disor- 
ders assume  a  terrifying  character.  Grimacing  and 
horrible  forms  are  seen  in  the  folds  of  the  curtains,  upon 
the  window-panes,  or  upon  the  walls.  Assassins  come 
out  of  every  corner;  the  patient  hears  clearly  their 
threats  and  abuses  and  describes  their  costumes  and 
their  weapons.  He  sees  frightful  and  fantastic  animals ; 
rats,  snakes,  gigantic  tigers  fill  the  room,  constantly 
changing  their  shapes  and  throwing  themselves  upon 
the  wretched  subject,  who  repels  them  with  desperate 
efforts.  An  odor  of  poison  proceeds  from  all  sides;  the 
food  has  a  putrid  taste. 

The  motor  activity  is  at  times  very  violent.  The  pa- 
tient walks  to  and  fro  in  the  dormitory  or  in  his  room, 
seeks  his  clothes,  strikes  the  walls  to  open  a  pass- 
ageway for  his  escape,  emits  cries  of  terror;  or  he 
whistles  and  sings,  assuming  in  the  intervals  a  conver- 
sational tone,  as  he  imagines  himself  surrounded  by  his 
acquaintances.     The  movements;  though  sudden  and 


154  MANUAL  OF   PSYCHIATRY. 

awkward,  always  have  a  psychic  origin  (Wernicke);  it 
is  true  that  they  are  determined  by  imaginary  represen- 
tations and  sensations,  but  they  Invariably  present  the 
character  of  "purposeful  acts.  The  patient  who  believes 
himself  to  be  in  his  workshop  goes  through  the  regular 
movements  necessary  for  the  performance  of  his  habitual 
work;  another,  the  victim"  of  terrifying  hallucinations, 
executes  the  movements  of  flight  or  of  defense. 

On  viewing  broadly  all  the  preceding  symptoms  we 
observe  that  the  hallucinations  of  delirium  tremens  are 
like  a  vivid  mobile  dream.  Just  as  a  sleeper  can  be  awak- 
ened, so  can  the  patient  be  momentarily  roused  from  his 
delirium  by  a  sudden  interpellation.  One  then  obtains 
correct  responses,  so  that  the  patient  may  create  the 
impression  of  a  normal  individual.  But  as  soon  as  he 
is  left  alone  he  relapses  into  his  delirium  and  agitation. 

Physical  symptoms. — The  tremor  of  chronic  alcohol- 
ism becomes  exaggerated  so  that  there  is  a  shaking  of 
the  entire  body. 

The  speech  presents  a  characteristic  tremulousness. 

At  times  a  slight  degree  of  syllabic  stuttering,  para- 
phasia, facial  paresis,  or  even  hemiparesis  appear,  show- 
ing the  participation  of  the  projection  centers  in  the  mor- 
bid process,  and  thus  establishing  a  point  of  contact 
between  delirium  tremens  and  general  paresis, — the 
psychic  disease  in  which  the  projection  centers  are 
most  profoundly  affected.1 

The  tendon  and  cutaneous  reflexes  are  usually  exag- 
gerated. 

A  certain  degree  of  hyperesthesia  is  the  rule.      The 

1  Bonhoffer.     Der  Geisteszustand  der  Alkoholdeliranten,  1897. 


CHRONIC  ALCOHOLISM.  155 

morbid  irritability  of  the  psycho-sensory  centers  ex- 
plains the  facility  with  which  it  is  possible,  by  a  simple 
suggestion  or  by  slight  mechanical  stimulation,  to  bring 
forth  a  hallucination,  even  after  the  spontaneous  psycho- 
sensory disorders  have  disappeared  (induced  hallu- 
cination's of  Liepmann).1 

We  encounter  also  paresthesias  and  even  anaes- 
thesias. 

Fever  is  almost  a  constant  symptom;  its  presence 
furnishes  an  excellent  element  for  prognosis  even 
regardless  of  all  complications.  In  favorable  cases  the 
temperature  does  not  rise  beyond  39°  C,  reaching  its 
maximum  towards  the  end  of  the  second  day.  Defer- 
vescence takes  place  either  rapidly  or  by  lysis.  In 
grave  cases  the  temperature  rises  above  39°  or  even 
40°  C. 

There  is  aiso  to  be  noted  a  dyspeptic  condition  of  the 
digestive  tract  which  is  often  very  marked;  usually 
a  slight,  sometimes  a  severe  albuminuria,  a  rapid,  full, 
and  bounding  pulse  which,  in  grave  forms,  becomes 
small  and  easily  compressible.  Under  these  unfavor- 
able circumstances  the  general  nutrition  suffers  and 
there  is  loss  of  flesh  which  becomes  very  considerable 
in  a  few  days. 

Complications. — Among  those  involving  the  nervous 
system  the  most  frequent  are  epileptiform  attacks 
which  often  precede  by  thirty-six  or  forty-eight  hours 
the  onset  of  delirium  tremens.  The  most  formidable 
as  well  as  the  most  common  complication  is  pneumonia, 


Arch.  f.  Psychiatrie,  XXVI. 


156  MANUAL  OF  PSYCHIATRY. 

which  affects  chiefly  the  apex  of  one  or  the  other  lung 
and  assumes  from  the  beginning  a  grave  aspect. 

Prognosis. — Recovery  is  the  rule.  It  takes  place 
within  four  or  five  days  after  a  deep  and  prolonged 
sleep.  The  sleep  may  come  on  suddenly  or  it  may 
be  preceded  by  a  period  of  calmness. 

The  duration  of  delirium  tremens  is  sometimes 
abnormally  brief  (several  hours),  and  at  other  times 
abnormally  long  (a  few  weeks  or  even  months). 

The  convalescence  is  marked  at  the  beginning  by  a 
certain  amount  of  confusion  which  persists  for  some 
time  and  which  may  or  may  not  be  associated  with 
some  delusions. 

Death  may  occur  from  exhaustion,  from  an  epilepti- 
form attack,  or  from  some  complication  (pneumonia). 

Diagnosis. — Attacks  very  similar  to  delirium  tremens 
are  seen  outside  of  alcoholism,  notably  in  senile  dementia, 
in  general  paresis,  and  in  meningitis  at  the  cerebral 
convexity.  In  the  latter  affection  the  diagnosis  is 
based  upon  the  existence  of  specially  marked  and 
numerous  focal  symptoms  such  as  Jacksonian  epilepsy, 
strabismus,  etc.,  upon  the  condition  of  the  optic  disc, 
and  upon  the  course  of  the  disease. 

The  elements  of  differentiation  from  general  paresis 
and  from  senile  dementia  will  be  studied  in  connection 
with  each  of  these  affections. 

Pathological  anatomy.  —  To  the  lesions  of  chronic 
alcoholism  already  considered  there  are  added  exudative 
hypercemia  and  inflammatory  diapedesis,  which  are  the 
expression  of  an  acute  process  analogous  to  that  observed 
in  infections. 
The  nerve-cells  lose  their  normal  shape  and  structure, 


CHRONIC  ALCOHOLISM.  157 

their  angles  become  blunted,  and  their  chromatophylic 
granulations  are  broken  up  or  disappear  entirely.  The 
nerve  fibers  degenerate. 

These  lesions  are  present  throughout  the  entire 
cortex,  including  the  centers  of  projection.  It  is  not 
rare  to  find  also  a  certain  degree  of  degeneration  in  the 
pyramidal  bundles  and  in  the  posterior  columns;  thus 
we  find  in  the  pathological  anatomy  a  confirmation  of 
the  relationship  which  has  been  clinically  shown  to 
exist  between  delirium  tremens  and  general  paresis 
(Bonhoffer) . 

The  visceral  lesions  are  often  dependent  upon  an 
infection  which  may  be  associated  with  the  alcoholic 
intoxication,  such  as  influenza,  infection  by  the  pneu- 
mococcus,  or  typhoid  fever. 

The  heart  is  the  seat  of  a  myocarditis  which  in  many 
of  the  fatal  cases  constitutes  the  immediate  cause  of 
death. 

The  liver  presents  a  degeneration  that  is  so  frequently 
met  with  and  at  times  so  pronounced  that  Klippel x 
has  been  led  to  think  that  delirium  tremens  may  be  the 
result  of  an  autoinfection  of  hepatic  origin. 

The  lesions  of  the  kidneys  are,  according  to  Herz,2 
those  of  acute  parenchymatous  nephritis.  He  states 
that  these  lesions  are  constant.  Thus  delirium  tremens 
would  seem  to  be  nothing  but  an  attack  of  ursemia  to 


1  Klippel.  Du  delire  des  alcooliques.  (Lesions  anatomiques  et 
pathogenic  Mercredi  medical,  Oct.  1893. — De  Vorigine  hepatique 
de  certains  delires  des  alcooliques,  Ann.  med.  psych.,  Sept.-Oct., 
1894. 

2  Abstract  in  Centralblatt  fur  Nervenheilkunde  und  Psychiatrie, 
May,  1898. 


158  MANUAL  OF  PSYCHIATRY. 

which  a  special  aspect  has  been  imparted  by  the  chronic 
alcoholism. 

Pathogenesis. — Delirium  tremens  is  not  to  be  con- 
sidered as  a  simple  alcoholic  intoxication,  a  sort  of 
belated  drunkenness  caused  by  an  accumulation  of  the 
poison  in  the  organism.  Its  clinical  aspect  in  fact 
differs  radically  from  acute  intoxication.  Moreover, 
the  attack  of  delirium  is  apt  to  break  out  even  after 
the  alcoholic  excesses  have  been  suspended  for  several 
days.  Finally,  the  patient  makes  a  perfect  recovery, 
even  if  alcohol  is  administered  to  him  in  large  doses 
during  the  course  of  the  delirium. 

Some  authors,  Wernicke  among  them,  attribute 
delirium  tremens  to  sudden  withdrawal  of  the  alcohol. 
Experience  does  not  seem  to  bear  out  this  opinion; 
we  meet  daily  with  inveterate  alcoholics  in  whom 
complete  abstinence  does  not  produce  the  slightest 
damage. 

An  important  fact  upon  which  Joffroy  frequently 
insists  in  his  lectures  is  that  delirium  tremens  often 
breaks  out  at  the  occasion  of  an  accidental  infection, 
such  as  influenza,  pneumonia,  or  suppuration.  Thus  it 
seems  that  the  disease  is  caused  by  two  agencies,  alco- 
holism on  the  one  hand  and  some  accidental  affection, 
most  frequently  an  infection,  on  the  other  hand. 

By  what  mechanism  does  their  combination  produce 
this  effect? — Possibly  by  determining  an  autointoxica- 
tion by  insufficiency  either  of  the  liver  (Klippel)  or  of 
the  kidneys  (Herz). 

It  should  be  remembered,  however,  that  in  many 
cases  the  second  factor,  the  accidental  infection,  is  not 
found.     Perhaps,  reduced  to  some  disorder  possessing 


CHRONIC  ALCOHOLISM.  159 

in  itself  no  apparent  gravity,  such  as  an  attack  of 
gastric  indigestion,  it  passes  unnoticed. 

Treatment. — Rest  in  bed  is  very  useful  and  is  appli- 
cable in  the  vast  majority  of  cases.  More  so  than  in 
any  other  psychosis,  in  this  disease  mechanical  restraint 
is  dangerous  and  is  to  be  prohibited. 

The  weak  heart  action  and  the  poor  condition  of 
the  liver  and  of  the  kidneys  oblige  the  physician  to 
make  but  very  little  use  of  hypnotics,  especially  in 
severe  cases.  The  most  serviceable  and  least  danger- 
ous are  chloral  and  paraldehyde,  which,  administered 
in  large  doses,  are  of  considerable  value.  They  should 
not  be  used  without  previously  excluding  the  likelihood 
of  collapse. 

Letulle  has  obtained  good  results  from  cold  baths. 

Alcohol  in  some  form  was  formerly  very  popular  as  a 
factor  in  the  treatment  of  delirium  tremens.  This 
practice  is,  however,  useless,  at  least  in  most  cases. 
When  the  patient's  forces  decline  rapidly  alcohol  may 
be  given  as  a  stimulant. 

Caffein  and  ether  in  subcutaneous  injections  often 
prevent  grave  cardiac  disturbances. 

The  food  should  be  substantial  and  should  be  such 
as  to  facilitate  the  elimination  of  toxines  accumulated 
in  the  organism.  A  milk  diet  admirably  fulfills  this 
double  indication.  Sometimes  it  is  useful  to  add 
eggs,  and  in  cases  where  there  is  much  weakness  beef- 
juice  or  chopped  meat  may  also  be  given. 

B.   ALCOHOLIC   SYSTEMATIZED    DELIRIUM. 

Alcoholic  systematized  delirium  differs  from  delirium 
tremens:     (1)    in   the   predominance   of   hallucinations 


160  MANUAL  OF  PSYCHIATRY. 

of  hearing  over  those  of  sight;  (2)  in  the  absence  of 
any  marked  disorders  of  consciousness;  and  (3)  in 
its  course,  which  most  frequently  presents  a  subacute 
character. 

After  a  rather  prolonged  prodromal  period  marked, 
as  in  the  case  of  delirium  tremens,  by  an  accentuation 
of  the  symptoms  of  chronic  alcoholism,  the  patient 
becomes  uneasy,  distrustful,  and  suspicious.  Gradually 
false  interpretations,  illusions,  and  persecutory  ideas 
become  established.  He  does  not  dare  to  leave  the 
house,  feeling  that  he  is  being  watched,  insulted,  or 
threatened  by  passers-by  or  followed  by  the  police. 
After  several  days  or  several  weeks  at  most  hallucina- 
tions of  hearing  appear  followed  often  by  hallucinations 
of  the  other  senses. 

The  disease  very  rapidly  reaches  its  highest  develop- 
ment and  then  presents  the  following  fundamental 
features : 

(a)  Conservation  of  lucidity:  the  patient  continues 
well  oriented,  understands  questions,  and  answers 
relevantly. 

(&)  The  painful  character  of  the  delusions  and  of  the 
psycho-sensory  disorders:  ideas  of  persecution  of  a  vari- 
able nature :  fear  of  being  poisoned  or  assassinated,  ideas 
of  jealousy;  imaginary  insults  or  threats;  frightful 
visions,  especially  marked  at  night,  grimacing  figures, 
ghosts,  detectives  coming  to  take  the  patient  into 
custody,  executioners,  etc.;  a  taste  or  an  odor  of  poison 
or  of  faecal  matter;  sensations  of  scalding,  pricking,  or 
electric  currents;  motor  hallucinations.  These  latter 
phenomena,  but  slightly  marked  in  the  majority  of 
cases,  point  to  a  grave  prognosis  when  they  assume  a 


CHRONIC  ALCOHOLISM.  161 

certain  intensity;  they  often  forebode  a  very  prolonged 
course  of  the  delirium  and  indicate  the  existence  of  a 
tendency  towards  intellectual  enfeeblement.  Hallu- 
cinations of  taste  and  smell  often  cause  refusal  of 
food. 

(c)  A  tendency  to  systematization:  the  subject  seeks 
an  explanation  and  a  cause  for  the  persecutions  of  which 
he  is  the  subject.  However,  the  systematization  is  of 
rapid  development  and  is  not  always  very  accurate, 
so  that  it  resembles  but  imperfectly  that  of  chronic 
delirium. 

(d)  A  depressed  mood  and  aggressive  tendencies:  the 
patient,  profoundly  irritated,  wreaks  his  vengeance 
upon  innocent  victims,  being  determined  to  defend 
himself  against  the  persecutions  of  his  enemies  or  to 
escape  them  by  any  possible  means.  If  such  a  patient 
desires  to  die  it  is  not,  as  is  the  case  with  other  classes 
of  patients,  for  the  purpose  of  expiating  some  crime 
or  of  finding  relief  from  remorse,  but  solely  to  escape 
the  frightful  tortures  prepared  for  him  by  his  enemies. 
Often  he  transforms  his  house  into  a  veritable  arsenal 
and,  unfortunately,  does  not  limit  himself  to  simple 
demonstrations,  but  makes  actual  use  of  his  weapons. 

The  somatic  disorders  of  chronic  alcoholism  are  all 
present  in  this  affection.  Sleep  is  diminished  and  filled 
with  the  pathognomic  dreams. 

The  urine  often  contains  a  trace  of  albumen,  which 
indicates  a  defective  condition  of  the  renal  functions. 

When  ideas  of  jealousy  predominate  the  affection 
merits  the  special  name  of  alcoholic  delirium  of  jealousy. 
The  hallucinations  in  such  cases  occupy  a  secondary 
position,  without,  however,   being   entirely   absent  in 


162  MANUAL  OF  PSYCHIATRY. 

any  case.  The  delusions  are  almost  always  absurd: 
the  proofs  that  the  patient  furnishes  of  his  wife's 
improper  conduct  are  childish.1 

As  a  general  rule  an  attack  of  alcoholic  systematized 
delirium  tends  towards  recovery.  This  takes  place 
gradually  after  several  weeks  or  at  most  several  months. 
The  ideas  of  jealousy  are  the  most  tenacious;  they 
may  persist  for  a  long  time  after  the  suppression  of  the 
alcohol. 

The  prognosis  is,  however,  not  altogether  favorable, 
firstly  because  relapses  are  to  be  feared,  and  secondly 
because  each  successive  attack  leaves  a  noticeable 
trace  upon  the  intelligence  and  accelerates  the  course 
of  alcoholic  dementia. 

It  is  of  great  importance  to  make  the  differential 
diagnosis  between  alcoholic  systematized  delirium  and 
the  other  affections  in  which  systematized  delusions 
are  encountered,  viz.,  dementia  prsecox,  chronic  delirium 
and  paranoia.  The  reader  is  referred  to  the  respective 
chapters  devoted  to  these  diseases  for  the  points  of 
differentiation. 

The  treatment  is  that  of  chronic  alcoholism.  The 
violent  reactions  of  the  patient  usually  necessitate 
commitment.  Attacks  of  agitation  are  to  be  treated 
by  the  usual  methods'. 


1  Villers.     Le   delire    de    la   jalousie.     Bruxelles,    1899. — Parant. 
he  delire  de  la  jalousie .     These  de  Paris,  1901. 


CHAPTER  V. 
CHRONIC  INTOXICATION  BY  THE  ALKALOIDS. 

§  1.   MORPHINOMANIA. 

Chronic  intoxication  by  morphine  brings  about  a 
condition  known  as  morphinism.  Morphinism  con- 
stitutes morphinomania  when  the  drug  has  become  a 
necessity  to  the  organism,  so  that  its  suppression 
causes  a  train  of  physical  and  psychical  disturbances 
known  as  the  symptoms  of  abstinence. 

Etiology. — The  study  of  the  etiology  of  morphino- 
mania involves  the  consideration  of  two  distinct  ques- 
tions: (1)  What  individuals  are  apt  to  become  mor- 
phinomaniacs?  (2)  How  does  one  become  a  morphin- 
omaniac? 

(1)  What  individuals  are  apt  to  become  morphino- 
maniacsf 

Morphine  is  no  longer,  as  it  was  formerly,  an  aristo- 
cratic poison  limited  to  the  upper  classes.  "Even 
rural  populations  are  no  longer  exempt  from  the  con- 
tagion;  and  the  fault  is  chiefly  with  the  physicians."  1 

Morphinomania  is  especially  frequent  among  those 
who,  on  account  of  their  profession  or  surroundings, 

1  Chambard.  Les  mor-phinomanes.  Bibliotheque  medicale 
Charcot-Debove. 

163 


164  MANUAL  OF  PSYCHIATRY. 

can  readily  procure  the  poison;  such  are  physicians, 
their  wives,  medical  students,  pharmacists,  nurses,  and 
laboratory  attendants. 

As  in  the  case  of  alcoholism,  the  character  of  the  soil 
is  here  also  an  important  factor.  The  less  energetic  and 
mentally  stable  the  individual  is  the  more  likely  he  is 
to  yield  to  the  seductive  influence  of  the  poison.  Thus 
we  find  that  morphinomaniacs  are  often  degenerates. 

(2)  How  does  one  become  a  morphinomaniacf — In 
many  ways,  but  chiefly: 

(a)  Through  medication:  many  subjects  receive  their 
first  injection  for  the  relief  of  some  painful  affection, 
as  hepatic  colic,  neuralgia,  or  tabes. 

(&)  Through  curiosity:  this  occurs  especially  among 
degenerates,  idlers,  individuals  who  are  tired  of  all 
ordinary  pleasures  and  are  longing  for  new  sensations, 
and  whose  unfortunate  tendency  is  still  farther  stimu- 
lated by  the  example  and  proselytism  of  other  mor- 
phinomaniacs. 

(c)  Through  the  need  of  a  cerebral  sedative  or  of  moral 
relief:  this  occurs  in  the  overworked  (soldiers  in  time 
of  war  or  young  people  during  difficult  examinations) 
and  in  those  who  are  driven  by  some  misfortune  or 
ill-luck  to  seek  in  morphine  a  consolation  for  their 
sorrows  and  disappointments. 

Doses. — The  action  of  the  poison  becoming  less 
effective  in  time,  the  doses  necessarily  increase  more 
or  less  rapidly.  The  maximum  doses  taken  daily  by 
different  patients  vary  greatly.  One  morphinomaniac, 
reported  by  Pichon,  was  in  the  habit  of  taking  nine 
grams  daily.  Most  patients  limit  themselves  to  smaller 
doses.    Of  the  one  hundred  and  twenty  subjects  com- 


CHRONIC  INTOXICATION  BY  THE  ALKALOIDS.    165 

prised  in  the  statistics  of  Piehon  eighty-four  took  from 
0.40  to  1.20  grams  daily. 

The  methods  of  morphinomaniacs. — The  places  usually 
selected  for  the  injections  are  the  arms,  forearms, 
thighs,  or  legs;  the  next  in  frequency  are  the  abdomen 
and  the  chest.  Aery  frequently  these  regions  are 
covered  with  scars  from  abscesses  caused  by  septic 
injections.  These  scars  constitute,  so  to  speak,  the 
stigma  of  morphinomania  and  often  enable  the  physician 
to  establish  the  diagnosis  in  spite  of  repeated  denials 
on  the  part  of  the  patient. 

Many  morphinomaniacs  take  their  injections  without 
regularity  or  precaution  and  at  any  opportunity ;  others, 
in  true  epicurean  fashion,  select  the  moment  and  con- 
ditions when  they  can  enjoy  most  profoundly  their 
favorite  pleasure.  Some,  again,  have  their  hours  regu- 
larly fixed,  use  only  accurately  prepared  solutions  of  a 
certain  strength,  and  take  all  antiseptic  precautions; 
many  take  their  daily  quantity  in  divided  doses ;  others 
take  a  single  large  dose  daily  in  order  to  obtain  the 
most  intense  effect. 

SYMPTOMS  AND   EVOLUTION. 

According  to  Chambard  four  periods  may  be  dis- 
tinguished in  the  career  of  a  morphinomaniac,  which 
succeed  each  other  by  imperceptible  gradations. 

First  period :  initiation  or  euphoria. — It  has  been  aptly 
called  the  honeymoon  of  the  morphinomaniac.  Under  the 
influence  of  the  morphine  physical  pains,  if  they  exist, 
disappear  or  become  abated,  the  organic  functions 
become  more  active,  and  the  mind  lapses  into  a  pleasant 
reverie;   ideas  form  themselves  without  any  effort  and 


166  MANUAL  OF  PSYCHIATRY 

combine  "to  form  ingenious  conceptions,  elaborate 
resolutions,  vast  enterprises  which,  alas,  are  never 
likely  to  last  through  the  day";  depressing  thoughts 
disappear  and  life  assumes  a  smiling  aspect. 

Second  period:  hesitation. — Many  subjects,  conscious 
of  their  danger,  make  efforts  to  escape  from  it.  They 
diminish  the  doses,  reduce  the  number  of  injections,  etc. 
Some  even  completely  discontinue  the  use  of  the  drug 
permanently  or  temporarily. 

The  period  of  hesitation  is  not  constantly  present; 
many  patients  by  reason  of  their  ignorance  or  lack  of 
determination  pass  directly  from  the  first  period  to 
the  third. 

Third  period:  morphinomania  proper.  —  The  poison 
has  now  impressed  its  stamp  upon  the  organism  and  has 
established  certain  permanent  symptoms.  Moreover,  its 
suppression  gives  rise  to  a  series  of  characteristic 
phenomena,  the  symptoms  of  abstinence. 

(A)  Permanent  symptoms. — (a)  Psychical  phenom- 
ena.— These  consist  in  a  general  weakening  of  the 
psychical  activity,  and  are  manifested  in  the  intellectual 
sphere  by  a  sluggishness  of  associations  and  an  impair- 
ment of  attention  contrasting  with  an  intact  orienta- 
tion and  a  perfect  lucidity,  and  b}'  a  retrograde  amnesia 
of  reproduction:  the  representations  are  in  some  way 
inhibited  but  not  destroyed. 

In  the  emotional  sphere  there  is  indifference  and 
atrophy  of  the  moral  sense.  All  the  aspirations  of  the 
patient  reduce  themselves  to  a  single  idea,  that  of  pro- 
curing morphine  by  any  possible  means:  disregard  for 
conventionalities,  swindling,  falsehoods,  violence,  all 
seem    to    him    permissible.     Many    morphinomaniacs 


CHRONIC  INTOXICATION   BY  THE  ALKALOIDS.     167 

obtain  their  morphine  from  the  druggist  on  false  pre- 
scriptions, others  sell  their  very  household  articles  to 
purchase  morphine  for  the  money. 

In  the  sphere  of  the  reactions  there  is  always  a  very 
marked  aboulia.  The  patient  is  conscious  of  the  ruin- 
ous results  of  his  inactivity,  but  has  not  the  power  to 
overcome  it.  This  symptom  appears  early  and  together 
with  the  indifference  forms  a  characteristic  feature 
of  the  mental  state  in  morphinomania. 

(b)  Physical  symptoms. — The  general  nutrition  always 
suffers:  loss  of  flesh,  pallor  of  the  skin,  etc. 

The  circulatory  apparatus  shows  a  general  atony. 
The  cardiac  impulse  is  weak;  the  peripheral  circula- 
tion is  sluggish;  there  are  transient  cedemas. 

The  temperature  is  often  subnormal.  A  case  of  mor- 
phine fever  has,  however,  been  reported  (Levinstein). 

Motility:  general  muscular  asthenia;  a  tendency  to 
fatigue;  tremors:  "slow,  regular  oscillations  resulting 
from  a  twisting  movement  of  the  limb  upon  itself."  1 

Sensibility:  slight  hyperesthesia  which  is  at  times 
unilateral ;  diminution  of  the  acuteness.  of  vision,  often 
dependent  upon  a  "pallor  of  the  optic  disc,  which  may 
advance  to  atrophy."  2 

The  pupils  are  frequently  myotic. 

The  tendon  reflexes  are  occasionally  diminished. 

(B)  Symptoms  of  abstinence. — When  the  hour  for  his 
injection  has  passed  the  morphinomaniac  becomes  rest- 
less, his  expression  becomes  anxious,  and  his  respirations 
accelerated.  A  state  of  anxiety  soon  appears,  accom- 
panied by  a  very  marked  inhibition  of  all  the  psychic 

1  Jouet.     Quoted  by  Chambard,  loc.  cit. 

2  Pichon.     Le  morphinisme,  1890. 


168  MANUAL  OP  PSYCHIATRY. 

functions.  The  patient  abandons  his  unfinished  work 
or  conversation  and  leaves,  complaining  that  he  is 
unable  to  bear  the  tortures  of  which  he  is  a  victim.  At 
the  same  time  there  is  the  appearance  of  the  pathogno- 
monic somatic  symptoms:  extreme  pallor  of  the  face, 
acceleration  and  weakening  of  the  pulse,  general  pros- 
tration, cold  sweats,  and  spells  of  yawning.  If  absti- 
nence continues  the  condition  may  become  alarming: 
obstinate  diarrhoea  appears  and  collapse  is  threatened. 

No  matter  how  grave  the  symptoms  become  an  injec- 
tion of  morphine  always  affords  instantaneous  relief. 

Occasionally  the  mental  symptoms  present  all  the 
features  of  a  veritable  acute  psychosis:  agitation^ 
anxiety,  persecutory  ideas,  psycho-sensory  disorders, 
excitement  simulating  that  of  mania;  these  may  be 
associated  with  hysteriform  or  epileptiform  attacks. 

Fourth  period:  cachexia. — The  symptoms  of  the 
preceding  period  become  more  marked.  The  psychic 
disaggregation  in  some  cases  resembles  true  dementia. 
The  craving  for  the  drug  is  greater  than  ever.  The 
loss  of  flesh  reduces  the  patient  almost  to  a  skeleton; 
the  stomach  rejects  the  food  and  a  permanent  and 
intractable  diarrhoea  becomes  established;  the  blood 
pressure  becomes  low,  the  cardiac  impulse  grows  weaker 
and  weaker,  the  pulse  becomes  small,  thready,  and 
irregular;  the  renal  changes,  which  are  frequent,  give 
rise  to  albuminuria. 

Numerous  complications  are  apt  to  appear,  render- 
ing the  prognosis  still  more  serious:  pulmonary 
tuberculosis,  furunculosis,  phlegmons  hasten  the  fatal 
termination,  which  occurs  at  the  end  of  the  fourth 
period. 


CHRONIC  INTOXICATION  BY  THE  ALKALOIDS.    169 

Associated  intoxications. — The  intoxicants,  the  abuse 
of  which  is  often  associated  with  morphine,  are  chiefly 
ether  and  cocaine.  Cocainomania  will  be  made  the 
object  of  special  study.  Ether,  absorbed  from  the 
respiratory  tract  or  from  the  digestive  passages,  brings 
about  a  state  of  euphoria  analogous  to  that  produced 
by  morphine.  In  certain  cases  there  is  a  period  of 
excitement  which  may  reach  the  intensity  of  delirium 
and  which  is  followed  by  comatose  sleep. 

Treatment.  —  Its  aim  is  the  discontinuance  of  the 
morphine.  This  may  be  attained  by  three  methods: 
the  sudden  method  (Levinstein),  the  rapid  method 
(Erlenmeyer),  and  the  gradual  method  (the  so-called 
French  method). 

The  suppression  of  morphine  or  demorphinization 
cannot  be  carried  out  outside  of  a  sanitarium  for  the 
following  two  reasons:  (1)  because  the  patient  should 
be,  in  case  of  threatened  collapse,  within  immediate 
reach  of  medical  aid;  (2)  because  only  a  rigorous 
supervision  can  prevent  the  patient  from  procuring  the 
drug  clandestinely. 

The  method  of  choice  is  rapid  suppression.  "It  is 
a  fact,  recognized  to-day  by  all  physicians  experienced 
in  the  treatment  of  morphinomania,  that  rapid  sup- 
pression is  the  best  method  of  treatment."  x  The 
period  of  demorphinization  lasts  from  five  to  twelve 
days.  The  principle  consists  in  diminishing  the  dose 
each  day  by  one  half  of  that  administered  on  the  pre- 
ceding day,  and  finally,  on  reaching  a  minute  ration, 
completely  suppressing  the  drug.     It  is  in  the  latter 

1  Sollier.  La  demorphinization.  Presse  medicale,  April  23  and 
July  6,  1898. 


170  MANUAL  OF  PSYCHIATRY. 

days  of  the  suppression  that  the  symptoms  of  abstinence 
appear  with  the  greatest  intensity.  Patients  who 
descend  without  much  difficulty  from  one  gram  or 
more  to  several  centigrams  experience  grave  disturb- 
ances when  they  are  deprived  of  this  minute  allowance. 

Adjuvant  therapy. — The  diet  should  be  tonic  and 
reconstructive.  In  the  cases  of  marked  cachexia  it  is 
advisable  to  improve  the  state  of  the  general  nutrition 
before  the  complete  demorphinization.1 

The  digestive  tract  and  the  heart  demand  special 
attention. 

Gastro-intestinal  disorders  may  be  prevented  by  the 
use  of  bicarbonate  of  soda  (2-6  grams  daily),  and  cardiac 
failure  by  heart  stimulants,  such  as  caffein,  strophan- 
thus,  and,  if  necessary,  digitalis. 

A  morphinomaniac  cannot  be  considered  recovered 
until  a  long  time  has  elapsed  after  the  suppression  of 
the  drug.  The  return  to  ordinary  life  is  for  him  a  critical 
moment;  for  this  reason  isolation  in  a  sanitarium  should 
be  continued  for  several  weeks  after  the  last  injec- 
tion.2 

This  prolonged  detention  is  further  justifiable  by 
the  grave  complications,  notably  fatal  epileptiform 
attacks,  which  may  occur  long  after  complete  demor- 
phinization. 

In  spite  of  all  these  precautions  permanent  cures  are 
the  exception  and  relapses  are  the  rule. 


1  Joffroy.  Traitement  de  la  morphinomanie.  Gaz.  hebd.  de  Med. 
et  de  Chirurgie,  1899  and  1900. 

2  [At  least  a  full  year's  sojourn  in  a  sanitarium  under  strict  super- 
vision is  necessary  for  the  more  or  less  successful  prevention  of 
relapses.    See  Kraepelin's  Lectures  on  Clinical  Psychiatry.] 


CHRONIC   INTOXICATION   BY  THE  ALKALOIDS.     171 
§  2.    COCAINOMANIA. 

It  seems  that  cocainomania  first  appeared  in  1878, 
when  Bentley  made  the  fatal  suggestion  of  treating 
morphinomania  by  means  of  injections  of  cocaine. 

Like  morphine,  cocaine  produces  immediately  after 
its  absorption  a  peculiar  state  of  euphoria  characterized 
chiefly  by  a  sense  of  vigor  and  energy.  The  craving 
becomes  established  after  the  first  few  injections, 
much  sooner  than  in  the  case  of  morphine. 

I  shall  describe  successively  the  habitual  mental 
state  of  the  cocainomaniac  and  the  cocaine  delirium. 

Habitual  state. — Normal  activity  is  replaced  by  in- 
dolence, and  the  affectivity  by  indifference.  All  the 
faculties  are  dulled.  The  memory  is  paralyzed,  there 
being  both  anterograde  amnesia  by  default  of  fixation 
and  retrograde  amnesia  by  default  of  reproduction. 
The  mood  is 'usually  sad,  gloomy,  and  pessimistic,  and 
the  will  power  is  nil. 

This  state  of  general  enfeeblement  is  interrupted  by 
sudden  outbreaks  of  gaiety  and  feverish  activity,  which 
disappear  very  soon,  leaving  behind  them  an  intensified 
psychasthenia. 

The  sensory  organs  are  the  seat  of  hyperesthesia,  so 
that  even  slight  stimulation  produces  painful  sensations. 
At  intervals  hallucinations  appear,  which  constitute 
the  germ  of  the  true  delirium.  Conscious  in  the  begin- 
ning, the  hallucinations  are  later  accepted  by  the  sub- 
ject as  real  sensations. 

The  general  nutrition  is  poor.  The  skin  assumes 
an  earthy  color;  the  weight  is  reduced;  the  process  of 
digestion  is  sluggish  and  painful;  and  there  is  diarrhoea 
alternating  with  constipation. 


172  MANUAL  OF  PSYCHIATRY. 

Cocaine  delirium. — It  is  a  delirium  of  a  painful 
character  associated  with  delusional  interpretations; 
its  main  features  consist  in  psycho-sensory  disorders 
which,  in  spite  of  their  extraordinary  distinctness,  are 
compatible  with  perfect  lucidity.  The  illusions  and 
hallucinations  may  affect  all  the  senses,  but  especially 
vision,  touch,  and  the  muscular  sense. 

Objects  change  their  shapes  and  are  constantly 
moving.  A  patient  of  Saury's  x  felt  himself  assailed 
by  a  swarm  of  bees  which  he  could  see  and  feel.  Many 
cocainomaniacs  feel  worms  creeping  over  their  bodies 
or  coming  out  of  their  flesh;  they  see  them,  seize  them 
with  their  fingers,  and  crush  them  under  their  feet. 
Many  also  perceive  imaginary  movements:  the  ground 
shakes  beneath  them,  their  bed  is  upset,  or  the  house 
they  are  in,  swept  by  a  flood,  floats  upon  the  waves. 
Hallucinations  of  hearing,  taste,  and  smell,  though  not 
rare,  occur  less  frequently  than  the  preceding  and 
present  no  special  characteristics. 

Sometimes  the  delusions  assume  the  form  of  morbid 
jealousy,  as  in  systematized  alcoholic  delirium. 

The  reactions  of  the  patient  are  governed  by  the 
delusions  and  are  often  violent. 

The  duration  of  the  attack  is  brief,  several  weeks  at 
the  longest,  and  in  some  cases  but  a  few  days.  I  have 
seen  a  typical  case  of  cocaine  delirium  terminate  in 
forty-eight  hours. 

The  treatment  consists  in  the  suppression  of  the  poison, 
which  can  in  the  great  majority  of  cases  be  accom- 
plished by  the  sudden  method  without  serious  incon- 
venience. 

1  Saury      Coculnom<mie.     Ann.  mod.  psych.,  1S89. 


CHAPTER  VI. 

PSYCHOSES     OF    AUTOINTOXICATION    ACUTE    AND 

SUBACUTE. 

§  1.  Uremic  Delirium. 

Uremic  delirium  presents  the  usual  features  of 
toxic  deliria:  more  or  less  complete  clouding  of  con- 
sciousness, disorientation,  phenomena  of  psychic  autom- 
atism, among  which  psycho-sensory  disorders  occupy  a 
prominent  place. 

The  delusions,  the  emotional  tone,  and  the  reactions 
enable  us  to  distinguish  two  principal  forms  of  ursemic 
delirium:   an  expansive  form  and  a  depressed  form. 

Expansive  form. — The  patient  is  a  great  personage,  a 
general,  a  prince;  he  assists  at  a  grand  review,  gives 
commands  to  his  officers,  or  orders  sixteen  horses  to  be 
harnessed  to  his  carriage;  the  Pope  presents  him  with 
the  imperial  crown. 

Often  the  delirium  takes  a  mystic  form:  the  heavens 
open,  celestial  music  is  heard,  or  angels  descend  on  an 
immense  ladder  as  in  Jacob's  dream. 

Depressed  form. — Melancholy  ideas  combine  with  ideas 

of   persecution   and   hallucinations   of   an   unpleasant 

character.     The  patient  imagines  people  are  searching 

for  him  to  drag  him  to  the  scaffold;    the  house  is  on 

fire;   an  odor  of  sulphur  is  diffused  through  the  air. 

173 


174  MANUAL  OF  PSYCHIATRY. 

Whatever  be  the  form  of  delirium,  the  reactions  are 
often  very  powerful  and  give  rise  to  violent,  at  times 
terrible,  agitation.  Often,  also,  in  the  melancholic 
and  mystic  forms,  there  is  marked  stupor  with  a  ten- 
dency to  cataleptoid  attitudes.1 

As  to  the  development  of  the  attack,  we  distinguish 
an  acute  form  characterized  by  severe  symptoms :  intense 
agitation  or,  on  the  contrary,  profound  stupor,  inces- 
sant hallucinations,  extreme  confusion  with  clouding 
of  consciousness,  etc. ;  and  a  subacute  form  characterized 
by  symptoms  of  lesser  intensity  and  by  periods  of 
comparative  lucidity  alternating  with  delirious  periods. 

In  some  exceptional  cases  of  ursemic  delirium  of  the 
subacute  form  the  delusions  become  systematized  and 
may  thus  be  misleading  in  the  diagnosis. 

The  mental  symptoms  of  ursemic  delirium  present  no 
pathognomonic  features  and  are  merely  the  manifesta- 
tion of  poisoning  of  the  cerebral  cells.  The  diagnosis 
must  be  made  from  the  accompanying  somatic  symp- 
toms: convulsive  attacks,  cardiovascular  disorders, 
dyspnoea,  cedema,  pupillary  manifestations, — myosis 
and  paresis  of  the  pupils, — diminution  of  the  specific 
gravity  and  of  the  toxicity  of  the  urine,  albuminuria, 
anuria,  oliguria,  or  polyuria. 

Uremic  delirium  is  often  very  similar  to  delirium 
tremens.  It  seems  that  the  two  affections  may  even 
be  combined.  Brault  2  is  of  the  opinion  that  uraemia, 
like  traumatism  or  pneumonia,  may  act  as  the  exciting 

1  Brissaud.  De  la  catatonie  brightique.  Sem.  med.,  1893. — 
Cullerre.  Sur  un  cas  de  folie  uremique  consecutij  a  un  retrecissement 
Iraumatique  de  Vurlihre.     Arch,  de  neurol.,  Vol.  XXVII,  No.  89. 

2  Traite  de  medecine,     Charcot-Bouchard.     Maladies  des  reins. 


PSYCHOSES  OF  AUTOINTOXICATION.  175 

cause  of  an  attack  of  delirium  tremens.  We  have 
already  seen  how  much  importance  is  attributed  by 
some  authors,  notably  by  Herz,  to  uraemia  as  a  patho- 
genic factor  in  delirium  tremens. 

The  prognosis  depends  upon  the  severity  of  the 
somatic  disturbances. 

The  treatment  is  that  of  ursemia  in  general:  milk 
diet,  blood-letting,   purgatives,   and  diaphoretics. 

§  2.  The  Polyneuritic  Psychosis. 

The  polyneuritic  psychosis  or  Korsakoff's  *  disease 
is  •  an  affection  constituted  by  the  association  of  the 
phenomena  of  polyneuritis  with  specific  mental  dis- 
orders, among  which  amnesia  of  diverse  forms  constitutes 
a  preponderant  feature. 

.  Etiology. — The  polyneuritic  psychosis  forms  from  an 
etiological  standpoint  a  transition  between  infectious 
psychoses,  toxic  psychoses,  and  psychoses  of  exhaus- 
tion. In  fact  infections,  intoxications,  and  exhaus- 
tion each  have  the  power  to  give  rise  to  the  disease: 
it  may  supervene  in  the  course  of  chronic  alcoholism, 
or  following  a  profuse  hemorrhage  or  an  infectious 
disease  such  as  influenza.  It  is  probable  that  all  of 
these  factors  produce  their  effect  by  the  same  mechan- 
ism,— most  likely  by  inducing  a  disorder  of  general 
nutrition  resulting  in  an  autointoxication.2 


1  Congres  de  Medecine,  1889. — Luckerath.  Beitrag  zu  der  Lehre 
von  der  Korsakow' schen  Psychose.     Neurol.  Centralblatt,  April,  1900. 

2  Therefore,  slightly  modifying  the  classification  of  Kraepelin, 
we  have  placed  the  polyneuritic  psychosis  not  among  the  infectious 
psychoses  proper,  but  among  the  psychoses  of  autointoxication. 


176  MANUAL   OF   PSYCHIATRY. 

Symptoms. — In  some  cases  the  symptoms  of  the  poly- 
neuritic psychosis  appear  gradually,  without  any 
striking  phenomena  at  the  onset;  much  more  often 
the  onset  is  acute:  agitation,  numerous  hallucinations, 
and  anxiety  render  the  resemblance  to  delirium  tremens 
so  marked  as  to  lead  very  frequently  to  errors  in 
diagnosis.  After  several  days  the  agitation  subsides, 
but  the  disorientation  persists  and  the  characteristic 
amnesia  appears  together  with  the  phenomena  of 
polyneuritis. 

The  amnesia  is  both  anterograde  and  retrograde. 

The  anterograde  amnesia  results  from  the  total  aboli- 
tion, or  at  least  a  marked  diminution,  of  the  power  of 
fixation.  The  patient  forgets  in  a  few  moments  a  visit 
which  he  has  received  or  the  gist  of  what  he  has  just 
read.  On  leaving  the  table  he  asks  whether  it  is  not 
almost  time  for  dinner  and  complains  of  having  no 
appetite. 

The  retrograde  amnesia  is  purely  functional,  by  default 
of  reproduction;  on  recovery  from  the  disease  the  old 
representations  reappear  intact. 

The  effacement  of  representations  occurs  in  confor- 
mation to  the  law  of  retrogression.  Depending  upon 
the  severity  of  a  particular  case,  the  amnesia  involves 
the  events  of  a  more  or  less  considerable  period  of  time. 

Imaginary  representations,  illusions,  and  hallucina- 
tions of  memory  fill  the  gaps  created  by  the  amnesia. 
Thus  quite  frequently  the  paitent  is  totally  unconscious 
of  the  disorder  of  memory  and  unhesitatingly  replies  to 
all  questions  put  to  him.  Often  also,  modif}dng  facts 
of  which  his  impression  is  more  or  less  vague,  adjust- 
ing some  details  and  suppressing  others,  the  patient 


PSYCHOSES  OF  AUTOINTOXICATION.  177 

narrates  imaginary  reminiscences  the  principal  features  of 
which  are  their  mobility,  their  easy  modifiability  by  appro- 
priate suggestions,  and  their  being  usually  limited  to  the 
bounds  of  possibility.  The  latter  characteristic  is,  how- 
ever, not  constant,  for  the  fabrications  in  the  polyneuritic 
psychosis  may  be  altogether  improbable  or  even  absurd. 

The  following  specimen  has  been  taken  from  an  obser- 
vation made  upon  a  case  of  polyneuritic  psychosis 
following  the  abuse  of  absinthe: 

Q.  Since  when  have  you  been  here? 

A.  Since  this  morning. 

Q.  What  were  you  doing  yesterday? 

A.  I  went  to  the  market  to  buy  some  eggs.  After 
that  I  went  to  see  my  sister  and  took  dinner  with  her. 

Q.  Don't  you  ever  go  to  the  theater? 

A.  Oh,  that's  true, ...  I  went  there  after  work  last 
night ...  it  was  very  beautiful. 

Q.  What  play  did  you  see? 

A.  Really . . .  just  wait  a  minute ...  it  was  very  beau- 
tiful . . .  they  sang . . .  they  had  superb  costumes ...  I 
cannot  recollect  the  name  of  the  play. 

In  reality  the  patient,  who  had  been  in  the  asylum 
during  the  three  weeks  previous,  had  not  left  his  bed 
since  his  admission  on  account  of  a  very  marked  paresis 
of  both  lower  extremities. 

To  these  pathognomonic  disturbances  of  memory  are 
added  also  complete  loss  of  orientation  of  time  and  place, 
numerous  illusions  which  often  assume  the  form  of 
false  recognitions,  and  occasional  hallucinations  which 
are  more  or  less  fleeting. 

The  emotional  tone  is  usually  one  of  indifference; 
sometimes  there  is  slight  euphoria. 


178  MANUAL  OF  PSYCHIATRY, 

In  spite  of  their  intensity  the  psychic  symptoms  are 
in  many  cases  not  very  apparent  at  the  beginning. 
The  patients  are  quiet,  understand  well  the  questions 
put  to  them,  and  reply  in  a  calm  and  often  even  in  an 
intelligent  manner.  They  often  appear  to  be  normal 
because  a  conversation  of  several  minutes  scarcely 
suffices  to  reveal  the  pathognomonic  amnesia  and  the 
disorientation. 

The  signs  of  polyneuritis,  paresis  of  the  lower  extremi- 
ties, abolition  of  the  tendon  reflexes,  paresthesias, 
lightning  pains,  hyperesthesias  of  circumscribed  mus- 
cular masses, — to  mention  only  the  principal  ones, — 
vary  widely  in  intensity.  They  are  at  times  mild, 
while  the  mental  disturbance  may  be  quite  marked. 
Possibly  they  may  be  even  entirely  wanting  in  certain 
cases  that  are  perfectly  typical  from  the  psychic  stand- 
point. 

The  general  health  is  always  affected  to  some  extent. 
Occasionally  a  cachexia  may  develop  and  end  fatally. 
Also  cardiac  disturbances  are  often  noted,  feeble  action, 
irregularity,  etc.,  which  in  a  number  of  cases  are  de- 
pendent upon  a  neuritis  of  the  pneumogastric  nerve. 

Duration,  prognosis.  —  The  duration  of  the  poly- 
neuritic psychosis  is  quite  long,  several  months  in  the 
majority  of  cases  and  sometimes  over  a  year. 

Three  modes  of  termination  are  possible: 

The  most  frequent  is  complete  recovery  with  restitutio 
ad  integrum.  Only  a  more  or  less  complete  amnesia 
for  occurrences  of  the  period  of  the  actue  symptoms 
remains.     Convalescence  is  much  prolonged.1 

f1  This  statement  is  not  borne  out  by  our  experience.  Of  twelve 
cases  observed  during  several  years  at  the  Long  Island  State  Hos- 


PSYCHOSES  OF  AUTOINTOXICATION.  179 

The  second  mode  of  termination,  much  less  frequent,  is 
death,  which  results  either  from  cachexia  or  from  some 
intercurrent  complication  (influenza,  pneumonia,  tuber- 
culosis) . 

The  third,  still  rarer,  is  the  passage  into  a  chronic 
state  tending  toward  dementia. 

The  diagnosis  is  to  be  baced  on :  (a)  the  very  marked 
and  characteristic  disorders  of  memory ;  (b)  the  appar- 
ent lucidity  of  the  patient,  contrasting  with  the  real 
disorientation;    (c)  the  coexisting  signs  of  polyneuritis. 

Treatment. — The  treatment  is  analogous  to  that  of 
acute  confusional  insanity;  it  consists  chiefly  in  rest 
in  bed  combined  with  a  reconstructive  diet. 

It  is  scarcely  necessary  to  add  that  abstinence  from 
all  alcoholic  beverages  should  be  rigorously  enforced, 
especially  when  alcoholism  is  the  cause. 

pital  not  one  resulted  in  complete  recovery;  in  all  of  them  there 
remained  a  more  or  less  pronounced  amnesia  with  a  tendency  to 
fabrications.  These  were  all  alcoholic  cases;  possibly  in  mild  cases 
and  in  cases  with  a  different  etiology  the  prognosis  is  more  favor- 
able.] 


CHAPTER  VII. 

PSYCHOSES    OF  CHRONIC  AUTOINTOXICATION. 

THRYOGENIC  PSYCHOSES. 

The  destruction  of  the  thyroid  gland  determines  a 
peculiar  autointoxication  which  is  met  with  in  two 
different  clinical  forms:  myxcedema  and  cretinism;  in 
the  former  the  destruction  of  the  gland  occurs  at  an 
adult  age,  in  the  latter  it  occurs  in  infancy. 

§  1.  Myxcedema. 

The  external  aspect  of  a  myxoedematous  patient  is 
characteristic.  The  puffed  and  expressionless  face 
together  with  the  general  attitude  reflect  both  the 
mental  inertia  and  the  profound  disorder  of  the  general 
nutrition. 

Psychic  disturbances. — These  consist  chiefly  in  symp- 
toms indicating  a  blunting  and  torpor  of  cerebral  activity, — 
psychic  paralysis:  there  is  extreme  sluggishness  of  the 
associations  of  ideas  demonstrable  by  simple  clinical 
examination  as  well  as  by  psychometry;  the  attention 
is  difficult  to  obtain  and  to  fix;  there  are  also  retro- 
grade amnesia  by  default  of  reproduction  and  antero- 
grade amnesia  by  default  of  fixation;  permanent  in- 
difference;  aboulia. 

180 


PSYCHOSES    OF   CHRONIC    AUTOINTOXICATION.   181 

The  indifference  is  occasionally  interrupted  by  tran- 
sient attacks  of  irritability.  Myxcedematous  patients 
are  often  sulky  and  ill-natured. 

Physical  disturbances. — The  sleep  is  diminished,  re- 
placed by  a  permanent  somnolence,  and  disturbed  by 
nightmares. 

The  reflexes  are  diminished  or  completely  abolished; 
all  movements  are  sluggish,  awkward,  and  clumsy. 

But  the  most  interesting  disorders  are  those  of  the 
integuments  and  of  the  thyroid  gland. 

Integuments. — The  skin  is  thickened  and  infiltrated; 
its  surface  is  smooth  and  of  a  dull  whiteness.  On 
palpation  it  gives  the  sensation  of  waxy  tissue.  There 
is  no  pitting  on  pressure,  this  being  the  point  of  dis- 
tinction between  myxcedematous  infiltration  and  ana- 
sarca. 

The  features  are  dulled,  the  eyes  sunken,  and  the 
lips  thickened;  the  wrinkles  of  the  forehead  disappear, 
and  the  naso-labial  fold  becomes  effaced.  The  physiog- 
nomy is  immovable  and  stupid.  The  hair  of  the  head, 
eyebrows,  and  beard  is  scant,  discolored,  and  atrophied. 
These  characteristics  are  pathognomonic  of  the  myxcede- 
matous facies. 

The  hair  over  the  entire  body  is  atrophied.  The 
nails  become  deformed  and  brittle. 

The  mucous  membranes  present  a  thickening  analo- 
gous to  that  of  the  skin.  They  are  pale,  ansemic,  and 
in  places  cyanotic. 

Thyroid  gland. — On  palpation  one  finds  atrophy  or 
even  complete  disappearance  of  the  gland. 

Sometimes  the  thyroid  gland  is  increased  in  size, 
causing  an  abnormal  prominence  in  front  of  the  neck. 


182  MANUAL  OF  PSYCHIATRY. 

This  hypertrophy,  true  or  false,  is  generally  transitory, 
and  occurs  chiefly  in  the  early  stages  of  the  disease. 
When  the  swelling  persists  through  the  entire  duration 
of  the  affection,  it  is  usually  the  result  of  a  cystic  degener- 
ation of  the  gland. 

The  visceral  disorders  do  not  present  any  charac- 
teristic features;  they  indicate  the  general  atony  and 
diminished  vitality  of  the  organism:  small,  compres- 
sible pulse,  sluggish  and  painful  digestion,  and  con- 
stipation. 

The  course  of  myxcedema  is  progressive,  but  inter- 
rupted by  frequent  remissions. 

If  no  appropriate  treatment  is  instituted,  the  stock  of 
ideas  becomes  diminished,  the  psychic  inertia  becomes 
extreme,  and  complete  dementia  is  established;  also 
the  physical  symptoms  become  accentuated  and  death 
supervenes  either  from  cachexia  or  from  some  compli- 
cation (pulmonary  tuberculosis). 

Treatment. — It  is  possible  to  supply,  to  a  certain 
extent,  the  deficiency  caused  by  atrophy  of  the  thyroid 
gland  by  the  administration  of  the  thyroid  gland  of 
animals  (almost  exclusively  that  of  the  sheep),  either 
in  the  crude  form  or  in  the  form  of  pharmaceutical  prep- 
arations. The  thyroid  substance  may  be  administered 
in  tablets,  pills,  or  capsules  containing  it,  either  in  the 
fresh  state  or  dried  and  reduced  to  a  powder.  The 
capsules  of  Vigier  contain  ten  centigrams  of  the  fresh 
gland;  they  may  be  administered  in  doses  as  high  as 
six  capsules  per  day  without  inconvenience. 

A  glycerine  extract  of  thyroid  gland  is  also  prepared 
and  is  known  by  the  name  of  thyroidine. 

Finally,  Baumann  and  Proos  have  extracted  from  the 


PSYCHOSES    OF    CHRONIC  AUTOINTOXICATION.   183 

sheep's  thyroid  a  substance,  iodothyrine,  which  seems 
to  be  the  active  principle.  This  substance  is  "  tritu- 
rated with  sugar  of  milk  in  such  proportions  that  one 
gram  of  the  mixture  represents  one  gram  of  the  fresh 
gland."  i 

Thyroid  medication  must  be  employed  with  great 
caution.  Toxic  symptoms  are  easily  produced :  acceler- 
ation of  the  pulse  and  respiration,  headache,  attacks  of 
vertigo,  and,  in  severe  cases,  a  tendency  to  collapse. 
Therefore  it  is  advisable  to  begin  the  treatment  with 
small  doses,  which  should  be  gradually  increased,  and 
promptly  reduced  or  suspended  entirely  on  the  appear- 
ance of  alarming  symptoms. 

The  mental  and  physical  effects  of  thyrotherapy  are 
very  rapid.  In  a  few  days  the  cerebral  torpor  becomes 
less  marked,  the  skin  reassumes  its  normal  aspect,  and 
the  other  myxoedematous  symptoms  become  abated. 

§  2.  Cretinism. 

Cretinism  may  be  defined  as  an  arrest  of  somatic  and 
psychic  development  dependent  generally  upon  a  goitre, 
and  more  rarely  upon  a  simple  atrophy  of  the  thyroid 
gland. 

The  affection  occurs  endemically  in  mountainous  re- 
gions, such  as  the  Alps,  the  Rocky  Mountains,  the  high 
plateaus  of  Himalaya,  Black  Forest,  etc.,  and  sporad- 
ically in  most  regions. 

Its  etiology  is  not  well  known.  Numerous  factors  are 
said  to  be  capable  of  causing  it:  atmospheric  humidity; 


1  Briquet.      Valeur    comparee     des     medications    thyroidiennes. 
Presse  medic,  1902,  No.  74. 


184  MANUAL  OF  PSYCHIATRY. 

geological  composition  of  the  soil  (cretinism  occurs  fre- 
quently in  countries  where  the  soil  is  composed  of 
schistose  clay  or  of  streaked  sandstone);  poor  quality 
of  the  water,  which  in  the  endemic  sections  is  poorly 
aerated,  deprived  of  iodine,  and  charged  with  calcium 
and  magnesium  salts;   want;   heredity. 

All  of  these  causes,  the  influence  of  which  should  be 
kept  in  view,  probably  only  prepare  the  soil  for  the 
action  of  some  specific  agent  still  unknown.  Accord- 
ing to  the  opinion  of  Griesinger,  "endemic  goitre  and 
cretinism  are  specific  diseases  produced  by  a  toxic  cause 
of  miasmatic  nature."  This  attitude  certainly  most 
nearly  corresponds  to  the  modern  medical  consensus 
of  opinion  and  has  at  present  the  greatest  number  of 
adherents.  In  fact  one  cannot  fail  to  note  the  similarity 
which  exists  between  the  etiology  of  endemic  goitre  and 
that  of  other  endemic  diseases  of  parasitic  or,  as  Grie- 
singer says,  miasmatic  origin,  such  as  malaria. 

The  symptoms  of  cretinism  usually  appear  in  early 
childhood.  Sometimes  the  onset  is  acute,  so  that  the 
destruction  of  the  gland  is  accomplished  in  a  few  days. 
Such  was  the  case  reported  by  Shields,1  in  which  an 
acute  thyroiditis  caused  the  destruction  of  the  thyroid 
gland  and  resulted  in  cretinism. 

Much  more  frequently  the  process  is  insidious,  and  it 
is  impossible  to  ascertain  the  exact  date  of  onset. 

The  size  of  the  goitre  is  variable.  The  swelling  may 
be  slight,  scarcely  perceptible,  or  so  enormous  as  to 
completely    disable    the    patient.     Resulting    usually 


1  A  case  of  cretinism  following  an  attack  of  acute  thyroiditis.     New 
York  Med.  Jour.,  Oct   1,  1898. 


PSYCHOSES  OF   CHRONIC   AUTOINTOXICATION.    185 

from  a  degeneration  of  the  thyroid  gland,  it  becomes 
evident  at  about  the  sixth  or  eighth  year  of  age  and 
increases  up  to  the  time  of  puberty  or  even  later. 

Simple  atrophy  of  the  gland  is  much  less  frequent  and 
is  seen  chiefly  in  sporadic  cases. 

Physically  the  cretin  exhibits,  in  addition  to  the 
changes  in  the  thyroid  gland,  the  following  symptoms: 
the  stature  is  below  the  normal;  the  face  is  pale,  puffed, 
pilous  or  marked  precociously  with  senile  wrinkles ;  the 
system  is  poorly  developed;  the  mucous  membranes 
are  pale,  anaemic,  and  thickened ;  the  teeth  are  abnormal 
in  shape  and  in  implantation  and  subject  to  caries; 
puberty  is  retarded  or  even  absent,  and  the  cretin  may 
remain  infantile  all  his  life. 

Psychically  we  encounter  all  degrees  of  idiocy  and 
imbecility.1  It  seems,  however,  that  the  cretin  is  less 
impulsive,  more  manageable,  and  more  capable  of 
emotional  activity  than  the  ordinary  idiot  or  imbecile.2 

The  brain  of  cretins  presents  no  known  specific 
lesions;  asymmetry  and  various  malformations  of  the 
hemispheres  are  frequent. 

The  treatment3  consists  in  thyroid  medication,  the 
results  of  which  are  the  more  perceptible  the  earlier 
it  is  instituted. 

1  See  Chap.  XVII,  p.  327. 

2  Bourneville.     Progres  medical,  1897. 

3  Ibid.,  1890. 


CHAPTER  VIII. 
DEMENTIA  PRECOX.— CHRONIC  DELIRIUM. 

§  1.  Dementia  Pilecox. 

Under  the  term  hebephrenia,  Hecker,  inspired  by 
his  preceptor,  Kahlbaum,  described  a  psychosis  which 
develops  by  predilection  at  the  age  of  puberty  and 
which  terminates  in  a  peculiar  state  of  intellectual 
enfeeblement. 

Later  Kraepelin  extended  the  views  of  Hecker  and 
added  to  this  group  catatonia,1  which  had  previously 
been  considered  an  independent  affection,  and  para- 
noid dementia,  which  includes  the  majority  of  cases 
of  systematized  deliria  commonly  assigned  to  the  vast 
and  ill-defined  group  of  paranoias.  This  fusion  resulted 
in  a  new  morbid  entity:    dementia  prcecox. 

At  the  same  time  the  problem  of  precocious  dementia, 
which  had  already  been  raised  by  Esquirol  and  Morel, 
but  had  been  neglected  since  their  time,  has  appeared 
anew  in  France.  Joffroy  presented  in  his  clinical  lec- 
tures cases  of  juvenile  dementia.  Christian  also  published 
under  the  title  Precocious  Dementia  in  Young  Individ- 
uals 2  an  important  work  based  upon  personal  obser- 


1  Kahlbaum.     Die  Katatonie  oder  das  Spannungsirresein,  1894. 

2  Christian.     De  la  demence  prccoce  des  jeunes  gens.     Contribution 

186 


DEMENTIA   PRECOX.— CHRONIC  DELIRIUM.       187 

vations.  More  recently  Serieux,  who  had  already  intro- 
duced the  ideas  of  Kraepelin  to  the  French  medical 
world,  published  a  clear  though  brief  monograph  upon 
this  new  affection,  based  upon  the  observations  of 
the  above-named  authors  as  well  as  upon  those  of 
his  own.  To-day  dementia  prcecox  occupies  a  promi- 
nent place  in  French  psychiatry,  the  framework  of 
which  it  has  profoundly  modified,  absorbing  a  large 
number  of  the  deliria  of  degenerates  (polymorphous 
deliria,  systematized  deliria,  etc.). 

The  disease  appears  in  many  forms  that  are  quite 
difficult  to  classify.  In  Germany,  following  Kraepelin, 
three  principal  forms  are  distinguished:  hebephrenia, 
catatonia,  and  paranoid  dement'ia.  Delusional  types 
of  hebephrenia  resemble  paranoid  dementia  so  closely 
that  it  is  often  impossible  to  determine  to '  which  of 
these  forms  a  given  case  is  to  be  assigned.  It  seems 
more  convenient  for  practical  purposes  to  describe 
separately  the  following  three  forms:  simple  dementia 
prsecox  without  delirium;  dementia  precox  of  the  cata- 
tonic form;  and  dementia  prsecox  of  the  delusional  form. 

Before  making  a  special  study  of  each  we  shall  describe 
the  symptoms  that  are  common  to  all  forms  of  the  dis- 
ease, especially  the  characteristic  intellectual  enfeeble- 
ment  which  is  the  basis  of  dementia  prsecox  and  which 
is  a  constant  feature. 


k  l'etude  de  l'hebephrenie.  Ann.  med.  psych.,  1899. — Serieux. 
La  nouvelle  classification  du  professeur  Kraepelin.  Rev.  de  psych., 
1900,  No.  4. 


188  MANUAL  OF  PSYCHIATRY. 


COMMON   SYMPTOMS. 

Intellectual  enfeeblement.1 — The  intellectual  enfeeble- 
ment  of  dementia  prsecox  is  essentially  elective.  It  affects 
certain  faculties  profoundly,  leaving  others  intact,  and 
thus  assumes  a  characteristic  aspect  which  places  it 
in  a  clearly  defined  position  in  the  group  of  demen- 
tias. 

Lucidity  and  orientation. — These  very  frequently  re- 
main intact,  although  the  appearance  of  the  patients 
would  scarcely  lead  one  to  think  so.  Many  patients 
appear  to  be  ignorant  of  what  occurs  about  them,  but 
nevertheless  reply  rationally  and  correctly  to  questions 
concerning  the  date,  their  surroundings,  and  even 
the  important  events  of  the  day.  We  shall  return 
to  this  question  in  connection  with  the  study  of  cata- 
tonia. 

Memory. — Like  the  lucidity,  the  memory  is  but 
slightly  affected,  at  least  in  the  majority  of  cases, 
for  a  considerable  number  of  years.  Old  impressions 
remain  well  defined,  and  the  knowledge  acquired  during 
youth  and  childhood  is  often  astonishingly  well  pre- 
served. An  old  asylum  inmate,  a  typical  case  of 
dementia  prsecox,  who  has  been  in  the  institution  for 
fifteen  years,  is  still  able  to  name  without  hesitation 
and  in  their  proper  succession  all  the  French  rulers 
from  the  time  of  Clovis. 

1  In  some  cases  of  dementia  prsecox  the  intellectual  enfeeblement 
involves  all  the  psychic  functions  and  is  at  times  so  marked  that 
all  mental  activity  seems  to  have  disappeared,  so  that  the  patient 
cannot,  from  this  point  of  view,  be  distinguished  from  an  idiot  or 
from  an  advanced  general  paretic.     Such  cases  are  exceptional. 


DEMENTIA  PRECOX.— CHRONIC  DELIRIUM.       189 

Actual  occurrences  impress  themselves  quite  durably 
upon  the  memory.  Many  patients  are  able  to  relate 
events  that  have  taken  place  since  their  commitment, 
and  can  often  even  name  the  physicians  and  attendants 
that  have  followed  each  other  on  the  service  during 
several  years. 

However,  when  the  affection  is  of  long  standing  it 
is  rare  for  the  memory  not  to  have  become  impaired 
to  some  extent.  Anterograde  amnesia  is  the  first  to 
appear:  the  capacity  of  fixation  becomes  diminished. 
Retrograde  amnesia  appears  later  and  is  usually  less 
marked.  Little  by  little  the  old  impressions  grow 
fainter  and  may  even  become  entirely  effaced. 

Attention. — This  faculty  is  always  weakened.  Any 
labor  requiring  some  degree  of  concentration  becomes 
impossible. 

Associations  of  ideas. — These  are  sluggish  and  often 
occur  without  any  apparent  connection,1  giving  rise 
to  speech  which  may  reach  the  extreme  limits  of  inco- 
herence. I  have  given  a  very  typical  example  of  such 
speech.  These  incoherent  phrases  are  uttered  quietly 
and  without  the  volubility  which  characterizes  the 
flight  of  ideas  of  the  maniac.  On  superficial  exami- 
nation this  phenomenon  may  create  the  impression  of 
a  profound  state  of  dementia  or  mental  confusion,  which 
in  reality  does  not  exist.  The  patient  whose  incoher- 
ent speech  we  have  quoted  as  a  typical  specimen  is 
perfectly  oriented  and  possesses  quite  a  good  memory. 
The  affectivity  and  reactions  are  greatly  impaired  from 
the  beginning.     Indifference  constitutes  an  early  and 

1  See  page  68. 


190  MANUAL  OF  PSYCHIATRY. 

very  prominent  symptom  of  dementia  prsecox.  The 
patient  takes  no  interest  in  anything,  expresses  no 
desires,  makes  no  complaints.  Often  even  hunger 
determines  no  reaction.  If  the  patient  is  accidentally 
forgotten  at  meal-time  he  evinces  no  surprise  and 
makes  no  protest.  As  in  all  conditions  of  dementia, 
this  disorder  of  affectivity  is  not  a  conscious  one. 

Occasionally,  especially  at  the  onset  of  the  illness, 
this  habitual  state  of  indifference  is  interrupted  by 
explosions  of  anxiety  or  of  anger,  for  which  there  is 
often  no  apparent  cause. 

A  priori  the  moral  indifference  of  dementia  prsecox 
would  be  expected  to  lead  to  a  reduction  of  the  volun- 
tary and  normal  reactions.  Actual  observations  upon 
patients  prove  that  this  is  really  the  case. 

On  the  other  hand,  the  automatic  reactions  are 
often  exaggerated.  They  manifest  themselves  under 
all  the  forms  studied  in  the  first  part  of  this  work, 
General  Psychiatry;  pathological  suggestibility,  nega- 
tivism, and  impulsiveness  (stereotypy  of  movements 
and  of  attitudes,  verbigeration,  grimaces,  unprovoked 
laughter,  etc.). 

Somatic  disorders. — The  number  of  known  somatic 
disorders  of  this  disease  is  constantly  increasing  as  the 
result  of  the  special  attention  recently  bestowed  upon 
the  subject  by  alienists.  Unfortunately  none  of  these 
bodily  signs  can  be  considered  as  constant  or  pathogno- 
monic. They  are  present  in  all  the  three  forms  of  the 
disease,  though  they  are  perhaps  more  marked  in  the 
catatonic  form. 

Motility. — Its  disorders  consist  in  hemiplegias  and 
monoplegias  that  are  slight  and  of  short  duration;  con- 


DEMENTIA   PRECOX— CHRONIC   DELIRIUM.       191 

vulsive  hysteriform  or  epileptiform  seizures,  to  which 
are  also  to  be  added  apoplectiform  attacks  so  closely 
simulating  true  apoplexy  as  to  be  liable  to  be  mistaken 
for  it.  The  contractures  often  observed  are  usually  the 
consequence  of  negativism. 

Sensibility. — One  must  be  guarded  against  attribu- 
ting the  absence  of  reaction  to  pricking,  which  results 
from  negativism,  to  anaesthesia.  True  disorders  of 
sensibility  are,  however,  far  from  being  exceptional. 
They  are  often  unilateral,  as  in  hysteria.  Other  hysteri- 
form symptoms  of  the  same  order  are  also  encountered: 
tender  areas,  clavus,  globus  hystericus,  etc. 

Tendon  reflexes. — Sometimes  diminished  or  abolished, 
much  more  frequently  exaggerated. 

Pupils. — Their  disorders  are  frequent  but  variable: 
inequality,  mydriasis,  sluggish  reactions,  the  phenome- 
non of  Piltz,  i.e.,  contraction  of  the  pupils  on  forcible 
closure  of  the  eyelids.  This  phenomenon  is  analogous 
to  the  following  one,  which  has  been  observed  at  the 
same  time,  independently,  also  by  Piltz  and  by  Westphal: 
"If  the  patient  attempts  to  shut  his  eyes  while  his  ef- 
fort is  opposed  by  the  examiner  who  holds  the  lids  apart 
forcibly  with  the  fingers,  a  contraction  of  the  pupils  takes 
place  while  the  eyeball  is  rolled  upward  and  outward."  1 

The  pupillary  disorders  often  undergo  fluctuations 
corresponding  to  those  of  the  mental  condition.  I 
recall  a  case  of  catatonia  in  which  the  intensity  of  the 
stupor  determined,  as  it  were,  the  degree  of  mydriasis. 
As  the  stupor  disappeared  the  pupils  reassumed  their 
normal  size. 

Circulatory  apparatus. — Vasomotor  disorders   causing 

1  Piltz.     Revue  neurologique,  1900,  No.  13. 


192  MANUAL  OF  PSYCHIATRY. 

cedenias,  cyanosis  of  the  extremities,  and  dermographia 
are  frequent.     Sometimes  the  pulse  is  slowed. 

The  temperature  may  be  subnormal  (Kraepelin).1 

Digestive  tract. — Indigestion,  anorexia,  and  constipa- 
tion are  often  found,  especially  during  the  acute  period. 
The  development  of  mental  enfeeblement  is  occasionally 
marked  by  boulimia. 

Urinary  apparatus. — Sometimes  there  is  polyuria,  at 
other  times,  on  the  contrary,  oliguria.  The  changes  in 
the  composition  of  the  urine  are  but  little  known.  A 
diminution  in  the  excretion  of  urea  and  of  phosphates 
has  been  found. 

Secretions. — We  know  nothing  of  the  disorders  of  the 
secretions  excepting  that  of  saliva,  which  in  some  cases 
is  greatly  increased. 

General  nutrition. — Its  changes,  though  undoubtedly 
of  great  importance,  are  as  yet  but  little  known.  The 
weight  is  reduced  in  the  acute  stages,  but  rises  again 
during  the  quiet  periods.  Some  precocious  dements 
present  a  remarkable  degree  of  corpulence. 

The  physical  phenomena  which  we  have  here  men- 
tioned are  difficult  to  account  for.  They,  however, 
enable  us  to  draw  the  very  interesting  conclusion  that 
the  morbid  process  of  unknown  nature,  and  psychically 
manifested  as  dementia  prsecox,  affects  not  only  the 
brain  but  the  entire  organism. 

A.    SIMPLE   DEMENTIA  PRECOX. 

I  shall  give  but  a  brief  description  of  this  interesting 
form,  which  unfortunately  has  received  but  little  atten- 
tion.    The  symptoms  of  mental  enfeeblement  described 

1  Lehrbuck  der  Psychiatrie,  Vol.  II,  p.  190. 


DEMENTIA  PRECOX.— CHRONIC  DELIRIUM.       193 

above  are  here  encountered  in  a  state  of  purity.  I  shall 
say  only  a  few  words  concerning  the  onset  of  the  disease. 

The  onset  is  almost  always  insidious,  and  it  is  usually 
impossible  to  determine  even  approximately  its  date. 
A  subject  previously  affectionate,  active,  intelligent, 
even  brilliant,  becomes  indifferent,  indolent,  and  dis- 
tracted. He  is  weary  of  everything,  of  play  as  well  as 
of  work.  He  ceases  to  acquire  new  ideas,  or  to  co- 
ordinate those  which  have  been  acquired  previously, 
so  that  his  stock  of  general  ideas  becomes  more  and 
more  limited. 

Nervous  symptoms  (headache,  insomnia,  hysteriform 
disturbances)  or  constitutional  symptoms  (anorexia, 
loss  of  flesh)  are  frequent,  especially  at  the  onset. 

In  the  mild  forms  the  disease  is  often  unrecognized. 
The  symptoms  of  intellectual  enfeeblement  pass  for 
" negligence"  or  "ill-humor."  Such  cases  occur  much 
more  frequently  than  is  commonly  believed. 

B.    CATATONIA. 

Onset. — Prodromata  are  almost  constant;  they  pos- 
sess no  specific  features:  change  of  disposition,  inapti- 
tude for  work,  insomnia. 

Often  the  symptoms  of  melancholia  open  the  series 
of  grave  phenomena.  In  themselves  they  present  no 
pathognomonic  features,  but  consist  merely  in  a  state 
of  depression  or  of  moral  pain  which  may  be  associated 
with  delusions  and  hallucinations. 

Soon  the  catatonic  phenomena  proper  appear;  they 
may  occur  also  at  the  onset  without  being  preceded 
by  the  period  of  depression  mentioned  above.  They 
depend  upon  a  disorder  of  affectivity,  moral  indifference, 


194  MANUAL  OF  PSYCHIATRY. 

and  a  disorder  of  the  reactions,  disappearance  of  the 
normal  will  associated  with  an  exaggeration  of  the  mental 
automatism.  Clinically  they  present  themselves  under 
two  principal  forms:  catatonic  excitement  and  catatonic 
stupor. 

Catatonic  excitement. — Sometimes,  especially  at  the 
beginning,  it  simulates  an  attack  of  confusional  insanity 
or  of  mania:  disordered  movements,  incoherent  speech, 
impulsive  reactions.  Soon,  however,  the  nature  of 
the  symptoms  becomes  more  definite  and  the  peculiar 
characteristics  of  catatonic  excitement  appear.  Its  prin- 
cipal features  are  four  in  number : 

(1)  Catatonic  excitement  is  free  from  any  emotion; 

(2)  It  is  not  influenced  by  external  impressions; 

(3)  It  is  not,  at  least  in  the  majority  of  cases,  gov- 
erned by  definite  delusions; 

(4)  It  is  monotonous  (stereotyped  movements,  ver- 
bigeration). 

In  other  words,  the  reactions  in  catatonic  excitement 
attain  the  extreme  limits  of  automatism. 

The  spells  of  excitement  occur  without  cause  in  an 
impulsive  and  unexpected  manner.  The  patient  per- 
forms most  singular  and  at  times  most  dangerous  acts 
without  being  able  to  furnish  any  explanation  for  his 
conduct  even  when  the  attack  has  passed  and  has  left 
in  his  mind  a  clear  recollection  of  all  that  he  has  done. 
A  catatonic,  perfectly  composed  an  instant  before,  leaves 
his  bed,  seizes  a  glass  and  throws  it  violently  at  the 
head  of  his  neighbor.  Another  breaks  to  pieces  a  ther- 
mometer imprudently  left  in  his  possession.  A  third 
calls  loudly  for  a  drink  of  water  while  holding  in  his 
hand  a  glass  filled  to  the  brim.     Some  display  for  weeks 


DEMENTIA  PRECOX— CHRONIC  DELIRIUM.       195 

or  months  suicidal  tendencies  without  there  being  any 
depressive  ideas  to  account  for  them. 

The  movements,  attitudes,  and  conversation  present 
stereotypy  and  verbigeration.  Often  the  patients  as- 
sume an  affected  or  dramatic  air.  Their  gestures, 
manners,  and  fantastic  dress  frequently  survive  the 
period  of  excitement  and  persist  through  the  quiet 
periods  and  the  terminal  dementia.  Some  patients 
will  hop  on  one  foot  for  months  instead  of  walking; 
others  will  invariably  respond  to  all  questions  by  the 
same  phrase ;  still  others  will  not  eat  their  food  without 
first  mixing  it  up  into  a  disgusting  mess;  others,  again, 
will  walk  back  and  forth  on  a  short  path  all  day  long, 
taking  alternately  a  certain  number  of  steps  forward 
and  the  same  number  backward.  Such  examples  could 
be  multiplied  infinitely.  Most  frequently  these  pecu- 
liarities in  the  conduct  of  the  patient  are  purely  auto- 
matic and  remain  inexplicable.  They  are  usually 
not  dependent  upon  delusions.  Their  origin  lies  in  a 
perversion  of  the  reactions,  and  not  in  any  disorder  of 
ideation  or  of  perception.  Although  delusions  and 
hallucinations  are  not  invariably  absent  in  catatonia, 
as  is  insisted  upon  by  Tschisch,  they  are,  however,  too 
rare  to  explain  the  anomalies  of  the  reactions,  which 
are  constant. 

Catatonic  stupor. — This  may  follow  a  period  of  depres- 
sion or  one  of  catatonic  excitement,  or  it  may  be  primary, 
constituting  the  onset  of  the  disease, 

In  its  true  sense  the  term  " stupor"  implies  the  exist- 
ence of  a  profound  disorder  of  consciousness.  In  this 
connection,  however,  the  word  is  used  in  a  different 
sense.    As  a  matter  of  fact  the  lucidity  is  but  slightly 


196  MANUAL   OF  PSYCHIATRY. 

if  at  all  affected  in  the  catatonic.  Impressions  of  the 
external  world  are  perceived  almost  normally.  Very 
frequently  the  patient,  though  apparently  unconscious 
of  his  surroundings,  relates,  after  the  stuporous  attack 
has  passed,  with  surprising  precision  the  facts  which 
would  seem  to  have  totally  escaped  his  observation. 

In  spite  of  appearances  catatonic  stupor  *  is  there- 
fore not  the  result  of  an  intellectual  disorder  proper, 
but,  like  catatonic  excitement,  of  a  disorder  of  the  will. 

The  automatism  of  the  reactions  is  met  with  in  three 
forms,  which  we  have  already  mentioned:  negativism, 
stereotypy,  and  pathological  suggestibility. 

The  negativism  is  manifested  in  simple  acts,  such  as 
movements  of  a  limb,  as  well  as  in  complex  acts,  such 
as  eating,  dressing,  etc.  The  patient  fails  to  react  to 
stimuli  either  from  the  external  world  or  from  his  own 
organism.2  An  order  given  is  not  executed.  Pricking, 
even  when  deep,  produces  no  movement,  not  because  it 
is  not  felt,  but  because  voluntary  reaction  is  annihilated. 
Hunger  produces  no  reaction.  The  urine  accumulates 
in  the  bladder,  the  saliva  in  the  mouth,  the  faecal  matter 
in  the  rectum  without  there  being  any  true  paralysis. 

Two  particularly  interesting  forms  of  negativism  are 
mutism  and  refusal  of  food.  Either  symptom  may 
persist  for  a  long  time  without  interruption  and  each 
may  present  very  diverse  characteristics. 

Stereotypy  is  seen  in  the  attitudes  and  in  the  physiog- 
nomy. 

1  Tschisch.  Die  Katatonie.  A  Russian  work  abstracted  in  Allgem. 
Zeitschr.  fiXr  Psychiatrie,   1900. 

2  Stoddart.  Anesthesia  in  the  Insane.  The  Journal  of  Mental 
Science,  Oct.   1899. 


DEMENTIA  PR/ECOX. -CHRONIC  DELIRIUM.      197 

Certain  patients  assume  very  singular  positions: 
extreme  flexion  of  the  limbs,  a  squatting  position,  the 
elbows  upon  the  knees,  the  head  drawn  back,  etc. 

The  physiognomy  of  the  patient  is  often  distorted 
by  grimaces.  The  lips  are  contorted  in  a  kind  of 
grin,  or  protruded,  as  though  the  patient  were  making 
faces.  The  eyes  may  be  closed  tightly.  These  phe- 
nomena may  persist  for  months  or  years.  Almost 
always,  at  least  in  the  beginning,  they  disappear  during 
sleep. 

Pathological  suggestibility  often  alternates  with  nega- 
tivism. Certain  cat  atonies  re  tarn  any  attitude  that 
they  may  be  placed  in,  even  the  most  uncomfortable 
(cataleptoid  attitudes).  Incapable  of  making  their 
toilet  they  submissively  allow  themselves  to  be  washed, 
combed,  and  dressed.  Many  become  filthy  and  soil 
and  wet  themselves  unless  taken  to  the  toilet  at  regular 
intervals.  Sometimes  a  single  impulse  suffices  to  start 
the  subject  and  make  him  accomplish  in  a  sort  of  me- 
chanical manner  some  habitual  act  or  even  series  of 
acts:  once  seated  at  the  table  with  his  plate  filled  in 
front  of  him,  he  may  eat  like  any  normal  person. 

Echolalia  and  echopraxia, — phenomena  which  are  also 
dependent  upon  suggestibility, — are  very  frequent. 

Like  the  excitement,  the  catatonic  stupor  is  essen- 
tially free  from  emotion. 

Excepting  the  very  rare  cases  in  which  the  disease 
terminates  in  recovery,  the  catatonic  comes  out  of  the 
agitation  or  the  stupor  with  more  or  less  intellectual 
enfeeblement.  Often  some  of  the  catatonic  phenomena 
persist,  thus  disclosing  the  origin  of  the  dementia: 
stereotyped  attitudes,  mannerisms,  verbigeration,  etc. 


198  MANUAL  OF  PSYCHIATRY. 

The  disease  often  develops  in  repeated  acute  attacks, 
each,  whatever  be  its  form,  leaving  behind  it  a  more 
advanced  degree  of  intellectual  enfeeblement.  Occa- 
sionally excitement  and  stupor  alternate  with  each 
other  with  a  certain  regularity,  simulating  circular 
insanity. 

C.    DEMENTIA  PILECOX   OF   THE    DELUSIONAL  FORM. 

The  prodromata  consist,  as  in  most  of  the  psychoses, 
in  change  of  disposition,  insomnia,  and  impairment  of 
the  general  health. 

Schematically  we  may  distinguish  in  the  delusional 
form  of  dementia  precox  two  extreme  types  which  are 
connected  by  a  great  many  intermediate  types :  (1)  The 
incoherent  type;    (2)  The  systematized  type. 

(i)  Dementia  prsecox  with  incoherent  delirium. — As 
this  name  indicates,  the  delusions  and  the  numerous 
hallucinations  which  usually  accompany  them  follow 
each  other  without  any  connection  or  governing  idea,, 
and  are  accepted  by  the  patient  as  they  appear,  without 
any  attempt  on  his  part  to  find  an  explanation  or  an 
interpretation  for  them. 

The  general  character  of  the  delusions  may  be  of 
three  varieties : 

(a)  Depressive  variety :  Melancholy  delusions  associated 
with  more  or  less  marked  depression  and  hallucinations 
of  a  painful  nature.  Often  ideas  of  persecution  are  added 
to  the  melancholy  ideas,  and  occasionally  even  predom- 
inate. It  is  not  rare  to  encounter,  especially  at  the  be- 
ginning of  the  disease,  attacks  of  very  pronounced  anx- 
iety, suicidal  ideas  and  attempts,  or  violent  tendencies. 

(6)  Maniacal   variety:     Excitement,   irritable    mood, 


DEMENTIA  PRECOX.— CHROXIC  DELIRIUM.       199 

morbid  euphoria,  ideas  of  grandeur  occasionally  asso- 
ciated with  ideas  of  persecution,  numerous  hallucina- 
tions, erotic  tendencies,  and  sometimes  a  certain  degree 
of  confusion. 

(c)  Mixed  variety:  The  two  preceding  varieties  are 
seldom  met  with  in  a  state  of  purity.  They  are  almost 
always  combined  with  each  other  in  one  of  two  different 
manners : 

(1)  States  of  depression  and  those  of  excitement 
alternate  without  any  order,  and  mutually  replace  each 
other  every  instant;  in  other  words,  the  delirium  is 
polymorphous. 

(2)  The  disease  develops  in  three  stages : 

I.  Depression  with  melancholy  delusions; 

II.  Excitement  with  expansive  delusions; 

III.  Dementia. 

Sometimes,  as  in  catatonia,  the  disease  assumes  a 
circular  type.  The  attacks  repeat  themselves,  each 
consisting  of  a  phase  of  depression  and  one  of  excitement 
and  leaving  behind  a  more  and  more  pronounced  state 
of  dementia. 

(2)  Dementia  praecox  with  systematized  delirium. — 
This  is  the  type  to  which  the  term  paranoid  dementia  is 
most  applicable.  The  systematization  of  the  delusions 
is  not  equally  accurate  in  all  cases.  Sometimes  it  is 
quite  perfect,  so  that  the  disease  resembles  chronic 
delirium.  In  other  cases  the  systematization  is,  on 
the  contrary,  so  imperfect  that  one  hesitates  to  classify 
the  case  among  the  precocious  dements  with  systema- 
tized delirium.  We  have  already  seen  that  there  exists 
between  the  two  delusional  forms  of  dementia  prsecox 
an  infinity  of  intermediate  forms. 


200  MANUAL  OF  PSYCHIATRY. 

Lucidity  is  preserved  except  during  the  transitory 
acute  paroxysms,  which  are  of  frequent  occurrence. 

Hallucinations  are  frequent  and  affect  all  the  senses. 

Dementia  supervenes  after  a  variable  period  of 
time,  which  is  in  some  cases  very  long.  As  it  progresses 
the  number  of  delusions  becomes  more  and  more  limited, 
the  hallucinations  diminish  in  frequency  and  in  intensity, 
and  the  reactions  become  weaker  and  weaker.  Often 
the  delirium  is  reduced  to  one  or  two  morbid  ideas, 
crystallized,  so  to  speak,  and  constituting  a  "  paranoic 
residue  "  which  remains  as  the  last  vestige  of  the  delirium 
originally  characterizing  the  affection.  Neologisms  are 
frequent  in  the  period  of  dementia. 

The  systematized  delirium  cf  dementia  prsecox  is 
met  with  in  three  principal  varieties : 

(a)  Persecutory  delirium; 

(6)  Melancholic  delirium; 

(c)  Megalomaniacal  delirium. 

(a)  Persecutory  variety. — The  delusions  may  either  ap- 
pear rapidly,  after  a  brief  period  of  prodromata,  or,  on 
the  contrary,  they  may  develop  slowly,  accompanied  at 
first  by  false  interpretations  and  only  later  by  hallucina- 
tions, as  in  chronic  delirium,  which  we  shall  soon  discuss. 

The  psycho-sensory  disorders,  hallucinations  and  illu- 
sions, are  constant,  of  an  unpleasant  nature,  and  may 
affect  any  of  the  senses.  Hallucinations  of  the  genital 
sense  are  frequent. 

The  reactions  consist  in  defensive  acts ;  these  reactions 
become  gradually  weaker  as  the  dementia  becomes 
established. 

The  dementia  is  often  announced  by  a  disaggregation 
of  the  personality,  which  gives  rise  to  autochthonous 


DEMENTIA  PRECOX.— CHRONIC  DELIRIUM.      201 

ideas,  psychomotor  hallucinations,  the  phenomena  of 
stealing  and  of  echo  of  the  thoughts,  etc.  The  time 
of  its  appearance  is  quite  variable.  Multiplicity  of 
hallucinations  usually  indicates  a  grave  prognosis  and 
points  to  a  rapid  evolution  towards  intellectual  enfeeble- 
ment. 

It  is  not  rare  to  note  some  degree  of  excitement 
appearing  in  paroxysmal  attacks. 

(b)  Melancholic  variety. — At  the  onset  the  melancholy 
ideas  present  no  peculiarity.  There  are  ideas  of  culpa- 
bility, humility,  ruin,  etc.,  as  in  the  melancholia  of 
involution  or  in  manic  depressive  insanity.  Later 
they  group  themselves  so  as  to  form  a  delusional 
system  which  persists  until  the  appearance  of  dementia. 

All  varieties  of  psycho-sensory  disturbances  are  met 
with.  The  most  important  are  psychomotor  hallu- 
cinations, which  are  of  quite  frequent  occurrence  and 
indicate  an  already  advanced  psychic  disaggregation. 

Mystic  ideas,  ideas  of  possession,  hypochondriacal 
ideas,  and  ideas  of  negation  are  frequent.  Occasionally 
the  symptoms  present  themselves  in  the  form  of  the 
syndrome  of  Cotard 

Attacks  of  anxiety,  common  in  the  beginning,  as  they 
are  in  all  psychoses  in  which  the  depressed  state  pre- 
dominates, become  less  and  less  frequent  as  the  peculiar 
indifference  of  dementia  prsecox  establishes  itself,  and 
the  most  frightful  delusions  often  exist  without  any 
emotional  reaction. 

As  in  the  preceding  form,  the  intellectual  enfeeblement 
often  takes  a  long  time  to  develop. 

(c)  Megalomaniacal  variety. — The  ideas  of  grandeur 
may  either  be   primary  or   they  may  follow  a  very 


202  MANUAL  OF  PSYCHIATRY. 

brief  period  of  ideas  of  persecution.  They  assume  the 
most  varied  forms.  The  patients  claim  to  be  owners 
of  immense  fortunes,  to  be  of  illustrious  descent,  to 
possess  remarkable  talents,  etc. 

The  hallucinations,  which  are  less  numerous  and 
less  constant  in  this  than  in  the  two  preceding  vari- 
eties, are  always  of  an  agreeable  nature.  The  develop- 
ment of  dementia  is  usually  rapid. 

(d)  Mixed  varieties. — The  three  preceding  varieties 
may  combine  with  each  other  so  as  to  form  four  principal 
mixed  types: 

Type  I :  Period  of  melancholia ;  period  of  persecutory 
ideas;   period  of  dementia. 

Type  II :  Period  of  melancholia;  perbd  of  persecutory 
ideas;  period  of  grandiose  ideas;  period  of  dementia. 

Type  III:  Period  of  melancholia;  period  of  grandiose 
ideas;   period  of  dementia. 

Type  IV:  Period  of  persecutory  ideas;  period  of 
grandiose  ideas;   period  of  dementia. 

The  different  periods  almost .  always  overlap  each 
other;  melancholy  ideas  and  ideas  of  persecution,  for 
instance,  often  coexist. 

DIAGNOSIS,    PROGNOSIS,   ETIOLOGY    AND    TREATMENT    OF 
DEMENTIA   PR.ECOX   IN   GENERAL. 

Diagnosis. — It  is  to  be  based  upon:  f 

(a)  The  early  appearance  of  the  disorders  of  the 
affectivity  and  of  the  reactions; 

(b)  The  dela}Ted  appearance  of  the  intellectual  dis- 
orders proper  and  their  less  marked  intensity; 

(c)  The  contrast  existing  in  most  cases  between  the 
delirium  and  the  emotional  tone; 


DEMENTIA   PRECOX.— CHRONIC  DELIRIUM.       203 

(d)  The  purely  automatic  character  of  the  excite- 
ment and  of  most  of  the  reactions. 

It  is  at  the  beginning  that  the  greatest  difficulty  in 
diagnosis  is  encountered. 

Mental  confusion  is  to  be  distinguished  by  the  much 
more  pronounced  disorientation,  the  much  more  real 
disorder,  so  to  speak,  of  the  consciousness,  and  by  the 
symptoms  of  profound  denutrition,  sometimes  of  true 
cachexia,  which  are  a  constant  manifestation  of  the 
disease. 

General  paresis  is  distinguished  by  the  intellectual 
enfeeblement  en  masse,  by  its  characteristic  physical 
signs,  and  by  its  special  etiology. 

Delirium  tremens,  which  may  be  simulated  by  the 
delirious  outbreaks  marking  the  onset  of  dementia 
prsecox,  is  recognized  by  the  pathognomonic  character 
of  the  hallucinations,  by  the  very  pronounced  allopsychic 
disorientation  contrasting  with  the  intact  autopsychic 
orientation,  and  by  the  stigmata  of  alcoholism. 

Systematized  alcoholic  delirium  is  often  very  difficult 
to  distinguish  from  the  delusional  form  of  dementia 
prgecox.  Special  attention  must  be  paid  to  the  etiology 
of  the  case  and  to  the  course  of  the  disease,  which  is 
more  favorable  in  alcoholic  delirium.  One  should,  how- 
ever, be  very  guarded  in  rendering  a  diagnosis  as  well 
as  a  prognosis.  In  practice  it  is  not  rare  to  meet  with 
inveterate  alcoholics  who  present,  after  an  attack  of 
alcoholic  systematized  delirium,  or  even  of  delirium 
tremens,  the  symptoms  of  dementia  prsecox  which 
subsequently  run  the  classical  course  and  to  which 
the  alcoholism  has  served  merely  as  a  portal  of 
entry. 


204  MANUAL  OF  PSYCHIATRY. 

Prognosis. — This  is  always  grave  as  the  most  usual 
outcome  is  dementia. 

The  intellectual  enfeeblement  is  sometimes  so  slight, 
it  is  true,  that  it  appears  only  as  a  scarcely  perceptible 
sluggishness  in  the  associations  of  ideas,  a  certain  degree 
of  moral  indifference,  and  a  tendency  to  intellectual 
fatigue. 

A  certain  number  of  patients  even  form  an  exception 
to  the  general  rule  and  recover  completely.  These 
cases  are  rare  and  are  to  be  accepted  only  with  extreme 
circumspection.  Many  of  the  apparently  complete 
recoveries  are  but  relative,  and  many  recoveries  con- 
sidered permanent  are  but  temporary;  that  is  to  say, 
they  are  mere  remissions. 

Indeed,  remissions  are  frequent  in  dementia  prsecox. 
Their  duration  varies  within  very  wide  limits,  from  a 
few  hours  to  several  years.  It  is  not  exceptional  for  a 
precocious  dement  to  come  out  of  his  first  attack  appar- 
ently unscathed,  resume  his  normal  life  for  five,  six, 
or  more  years,  suffer  a  recurrence,  and  end  with  dementia. 

It  is  difficult,  not  to  say  impossible,  to  predict  the 
remissions.  The  intense  symptoms,  such  as  marked 
excitement  or  extreme  negativism,  do  not  exclude  the 
possibility.  Moral  indifference,  on  the  contrary,  scarcely 
recedes  at  all  when  it  is  clearly  established,  and  does 
not  permit  of  a  restitutio  ad  integrum.  Therefore  simple 
dementia  precox,  in  which  this  symptom  predominates, 
is  not  likely  to  be  interrupted  by  remission  in  the  great 
majority  of  cases. 

Dementia  praecox  is  not  in  itself  a  fatal  disease.  It 
may  terminate  fatally  from  the  complications  which 
it  is  sometimes  accompanied  by.     The  most  formidable 


DEMENTIA  PRECOX.— CHRONIC  DELIRIUM.      205 

of  these  is  pulmonary  tuberculosis,  which  is  apt  to 
attack  patients  in  a  state  of  depression  or  in  catatonic 
stupor. 

Etiology. — Statistics  show  that  dementia  precox  is 
chiefly  a  disease  of  young  life.  According  to  Kraepelin, 
in  sixty  per  cent,  of  the  cases  it  begins  before  the  twenty- 
fifth  year.  It  is  rare  after  the  age  of  thirty.  It  seems, 
however,  difficult  to  state  after  which  year  it  entirely 
ceases  to  appear.  Certain  psychoses  are  met  with  at 
an  advanced  age  identical  with  it  in  symptoms  and 
evolution.  But  such  irregularities  are  not  limited  to 
psychiatry.  Miliary  tuberculosis  is  chiefly  an  affection 
of  childhood  and  youth;  it  is,  however,  also  met  with 
in  elderly  people.  Is  it  surprising,  therefore,  that  a 
psychosis  presenting  all  the  features  of  dementia  precox 
should  be  found  by  way  of  exception  in  middle-aged  or 
even  in  old  individuals? 

Heredity,  though  less  frequent  than  in  some  other 
psychoses,  exists  nevertheless  in  more  than  half  of  the 
cases. 

The  severe  infections,  overwork,  grief,  and  trauma- 
tisms are  often  found  in  the  history  of  dementia  prsecox, 
but  it  seems  impossible  to  determine  the  part  played 
by  these  different  factors.  Von  Muralt  has  observed 
several  cases  of  catatonia  following  traumatism.  I  saw 
a  case  of  catatonia  in  which  the  disorder  was  preceded 
by  a  very  severe  attack  of  scarlet  fever;  also  a  case  of 
paranoid  dementia  in  which  the  mental  trouble  was 
preceded  by  typhoid  fever. 

The  intimate  nature  of  the  disease  has  so  far  escaped 
us,  and  we  must  be  content  for  the  present  with 
hypotheses. 


206  MANUAL  OF  PSYCHIATRY. 

According  to  some  authors  dementia  prsecox  results 
from  an  arrest  of  intellectual  development:  the  brain 
ceases  to  acquire  new  impressions,  being  exhausted  by 
previous  efforts  which  were  too  great  for  the  energy 
which  it.  originally  possessed.  This  explanation,  as- 
suming it  to  be  correct,  can  account  for  but  a  small 
number  of  cases.  In  reality,  in  most  of  the  patients 
we  observe  not  a  simple  statu  quo,  but  a  true  retrogres- 
sion. Facts  that  have  been  acquired  partly  disappear, 
or  at  least  cease  to  be  co-ordinated  so  as  to  give  rise  to 
generalized  ideas.  Moreover,  the  disorders  of  affectivity 
and  of  the  will  cannot  be  accounted  for  by  a  simple 
arrest  of  development. 

The  most  probable  hypothesis  is  that  of  Kraepelin: 
dementia  prsecox  is  a  disease  of  autointoxication.  Many 
of  the  physical  symptoms  described  above  resemble  the 
phenomena  by  which  intoxications  of  exogenous  or 
of  endogenous  origin  are  usually  manifested:  epilepti- 
form attacks,  hysteriform  disturbances,  disorders  of 
the  circulation  and  of  the  secretions,  and  alterations  of 
the  general  nutrition. 

Possibly  the  poison  is  the  consequence  of  a  disorder 
of  secretion  of  the  genital  organs.  The  frequent  appear- 
ance of  the  first  symptoms  at  the  age  of  puberty,  or  in 
the  female  at  the  time  of  her  first  childbirth,  and  the 
occasional  development  of  the  disease  in  interrupted 
stages,  each  corresponding  to  a  period  of  pregnancy, 
are  arguments  in  favor  of  this  hypothesis. 

Treatment. — This  is  reduced  to  the  treatment  of  the 
principal  symptoms  by  the  usual  methods.  An  effort 
should  be  made  to  combat  stereotypy  in  all  its  forms  by 
appropriate  suggestion  and  by  some  occupation,  when- 


DEMENTIA  PILIuCOX.— CHRONIC   DELIRIUM.       207 

ever  it  is  possible  to  make  the  patient  do  any  work,  which 
is  quite  frequently  the  case:  the  precocious  dements 
constitute  a  great  proportion  of  the  asylum  workers. 

§  2.  Chronic  Delirium. 

Isolated  by  Magnan  from  the  poorly  defined  group 
of  persecutory  deliria,  chronic  delirium  presents  a  strik- 
ing analogy  to  certain  forms  of  dementia  prsecox,  which 
fact  has  led  Kraepelin  to  include  it  under  the  heading 
of  paranoid  dementia.  Conforming  to  French  usage, 
I  shall  describe  it  as  a  separate  morbid  entity,  which 
appears  to  me  to  be  justifiable,  at  least  provisionally, 
in  view  of  the  following  considerations: 

(1)  Chronic  delirium  appears  at  an  age  when  dementia 
praecox  is  already  rare, — after  thirty  years  in  the  ma- 
jority of  cases; 

(2)  It  presents  a  perfect  systematization  and  a 
regular  evolution,  which  are  unusual  in  dementia 
prsecox; 

(3)  The  dementia  does  not  appear  for  many  years. 
Sometimes  it  does  not  appear  at  all,  even  when  the 
patient  has  reached  an  advanced  age  (Falret). 

The  name  * '  dementia  prsecox  "  would  scracely  be  appli- 
cable to  an  affection  usually  appearing  at  an  adult  age, 
and  in  which  intellectual  enfeeblement  does  not  super- 
vene until  long  after  the  onset, — twenty  years  or  more. 
Though  we  may  consider  chronic  delirium  as  very 
closely  related  to  dementia  prsecox,  it  would  seem  that 
more  facts  are  necessary  to  establish  the  identity  of 
the  two  diseases. 

The  evolution  of  chronic  delirium  occurs  in  four 
periods,  which  we  shall  consider  hastily,  for  the  symp- 


208  MANUAL  OF  PSYCHIATRY. 

toms  encountered  in  each  of  these  periods  have  already 
been  studied  by  us,  and  it  is  but  the  special  grouping 
of  these  symptoms  that  gives  the  disease  its  character- 
istic aspect. 

First  period:  incubation. — This  period  is  always  a 
prolonged  one.  The  personality  of  the  patient  under- 
goes a  slow  and  insensible,  though  profound,  trans- 
formation. The  symptoms  observed  at  the  beginning 
present  no  definite  character.  They  consist  in  an 
irritability  and  a  singular  pessimism,  with  which  are 
often  associated  hypochondriacal  ideas. 

Little  by  little  these  pathological  phenomena  become 
more  and  more  marked  and  develop  into  ideas  of  per- 
secution. Suspiciousness  and  uneasiness  appear  first, 
followed  later  by  delusional  interpretations:  the  patient 
thinks  himself  watched  as  he  walks  in  the  street,  or 
discovers  a  hidden  meaning  in  a  conversation.  Illu- 
sions of  all  the  senses,  but  especially  those  of  hearing 
and  of  smell,  gradually  appear  as  the  affection  reaches 
the  second  period. 

Second  period:  systematization  of  the  delusions; 
appearance  of  hallucinations. — Hallucinations  are  con- 
stant and  affect  all  of  the  senses  except  vision.  They 
are  always  of  a  painful  character.  The  first  to  appear 
are  the  phonemes  (verbal  auditory  hallucinations), 
which,  vague  at  the  beginning,  assume  after  a  certain 
time  remarkable  distinctness.  They  are  followed  by 
the  appearance  of  hallucinations  of  taste,  smell,  general 
sensibility,  including  the  genital  sense,  and,  later  on,  by 
motor  hallucinations  also. 

Visual  hallucinations  are  extremely  rare,  if  ever 
present  at  all.     On  the  other  hand,  illusions  of  sight  are 


DEMENTIA  PR/ECOX.— CHRONIC  DELIRIUM.      209 

as  frequent  as  those  of  the  other  senses,  often  taking 
the  form  of  false  recognitions. 

Little  by  little  the  delusions  group  themselves  and 
become  systematized.  The  hallucinations  are  inter- 
preted and  explained.  The  patient  recognizes  the 
voices,  discovers  his  persecutors,  the  methods  they 
make  use  of,  and  the  aims  they  pursue.  As  he  is  per- 
fectly convinced  of  the  reality  of  his  delusions,  he  reacts, 
seeking  to  protect  himself  against  his  imaginary  enemies, 
and  to  find  justice.  The  means  to  which  he  may  resort 
are  infinitely  varied:  protests  before  authorities  and 
before  the  public,  frequent  changing  of  residence,  and 
too  frequently  even  assaults  and  murder. 

As  the  disease  advances,  more  and  more  evident 
signs  of  psychic  disaggregation  appear:  echo  of  the 
thoughts,  autochthonous  ideas,  numerous  motor  hallu- 
cinations, etc. 

Third  period :  ideas  of  grandeur.  —  Some  authors 
look  upon  the  ideas  of  grandeur  as  a  logical  sequence  of 
those  of  persecution,  resulting  from  the  following  line  of 
reasoning,  which  the  patient  pursues  more  or  less  con- 
sciously: "They  persecute  me  so  unmercifully  and 
with  such  stubbornness  because  they  are  afraid  of  me 
or  jealous  of  me."  This  explanation  is  perhaps  appli- 
cable to  a  small  number  of  cases,  but  not  generally 
so. 

The  real  cause  of  the  ideas  of  grandeur  is  invariably 
the  intellectual  enfeeblement  which  begins  to  manifest 
itself  at  this  period. 

They  assume  all  possible  forms:  ideas  of  wealth,  of 
power,  or  of  transformation  of  the  personality.  One 
patient  was    God  and  his  persecutor  was  the  devil. 


210  MANUAL  OF  PSYCHIATRY. 

Another  reigned  over  the  planet  Mars,  and  once  decided 
to  destroy  the  earth  by  means  of  aeroliths. 

Fourth  period:  dementia. — Intellectual  enfeeblement 
here  becomes  clearly  apparent.  It  is  very  similar 
to,  if  not  identical  with,  that  of  dementia  prsecox,  and 
this  is  undoubtedly  strong  evidence  of  a  close  relation- 
ship existing  between  the  two  diseases. 

Almost  always  some  stereotyped  delusions  persist  as 
a  last  remnant  of  the  former  delirium. 

The  evolution  of  the  disease  is  very  slow,  often  requir- 
ing twenty  or  thirty  years  for  its  completion. 

The  prognosis  is  fatal  from  the  psychical  standpoint. 
But  the  morbid  process  does  not  affect  the  organic 
f mictions,  and  the  patients  may  live  to  an  old  age. 

Chronic  delirium  in  its  typical  form,  as  described  by 
Magnan,  is  a  very  rare  disease.  Heredity  is  here  found 
as  frequently  as  in  most  other  psychoses,  including 
dementia  praecox.  But  the  predisposition,  is  often 
entirely  latent,  the  disease  often  developing  in  sub- 
jects previously  of  normal  intelligence.  Perhaps  it  is 
to  this  fact  that  the  perfect  systematization  of  the 
delirium  and  its  extremely  slow  development  are  to 
be  attributed. 

May  we  assume  that  this  affection,  like  dementia 
precox,  is  due  to  an  autointoxication?  This  is  a 
question  which  the  future  alone  can  answer. 

The  treatment  is  limited  to  a  careful  supervision  which 
in  most  cases  cannot  be  carried  out  outside  of  an  asylum. 


CHAPTER  IX. 
GENERAL  PARESIS. 

Synonyms. — Chronic  arachnitis  and  chronic  meningitis  (Bayle). 
Incomplete  general  paralysis  (Delaye) .  General  paralysis  of  the 
insane  or  chronic  diffuse  periencephalo-meningitis  (Calmiel) .  Para- 
lytic insanity  (Parchappe).  Progressive  general  paralysis  (Lunier, 
Sadras) .  Paralytic  dementia  (Baillarger) .  Chronic  diffuse  inter- 
stitial encephalitis  (Magnan).  In  German:  Progressive  allgemeine 
Paralyse.  In  general  it  is  convenient  to  employ  the  Latin  term 
dementia  paralytica. 

The  earliest  mention  of  the  somatic  and  psychical 
disorders  corresponding  to  general  paralysis  dates  back 
to  1798,  when  Harlan,  pharmacist  at  the  Bedlam 
Hospital,  described  in  a  few  lines  and  with  remarkable 
precision  the  principal  features  of  the  disease. 

It  was  only  in  1822,  thanks  to  the  memorable  work 
of  Bayle,  that  general  paralysis  gained  a  footing  in 
classical  psychiatry.  The  history  of  this  disease  is  a 
subject  much  too  vast  for  the  limits  of  this  work.  It 
has  been  quite  recently  treated  by  Vignaud l  in  his 
inaugural  thesis,  which  contains,  in  addition  to  a 
good  bibliography,  a  very  clear  exposition  of  opinions 
and  theories  advanced  on  the  question  of  general 
paralysis  from  the  point  of  view  of  its  pathogenesis  as 


Histoire  de  la  paralysie  generate.     Paris.     These. 

211 


212  MANUAL  OF  PSYCHIATRY. 

well    as  from  that   of    its   etiology   and    anatomical 
lesions.1 

Prodromal  period. — It  is  marked  (a)  by  changes  of 
the  affectivity  and  of  the  character;  (b)  by  phenomena 
of  neurasthenia  and  psychasthenia. 

(a)  The  mood  becomes  either  irritable  and  change- 
able, with  sudden  alternations  of  joy  and  sorrow,  kind- 
ness and  anger,  discouragement  and  optimism;  or 
gloomy,  and  marked  by  pessimism  and  by  a  tcedium 
vitce  which  may  lead  the  patient  to  attempts  at  suicide. 
Often  the  patient  is  conscious  of  being  stricken  with 
a  grave  disease  and  has  dark  presentiments  for  the 
future. 

(b)  The  neurasthenic  and  psychasthenic  symptoms  are 
usually  very  pronounced :  a  feeling  of  general  lassitude, 
fatigue,  muscular  weakness,  diffuse  neuralgic  pains, 
headache,  a  sort  of  grinding  sensation  felt  especially 
in  the  head,  and  .other  peculiar  sensations  which  the 
patient  is  unable  to  describe  clearly:  it  may  seem  to 
him  that  his  head  is  empty,  that  his  brain  is  falling  to 
pieces,  etc. 


1  Monographs  on  general  paresis :  Lasegue.  De  la  paralysie 
generate  progressive.  Th.  d'agreg.  Paris,  1853;  also  Lecons  sur 
la  paralysie  generate,  1883. — Falret.  Recherches  sur  la  jolie  paraly- 
tique  et  les  diverses  paralysies.  Paris,  1853. — Voisin.  Traite  de 
la  paralysie  generate.  1879. — Baillarger.  Theorie  de  la  paralysie 
generate.  Ann.  mecl  psych.,  1883. — Mendel.  Die  progressive 
allgemeine  Paralyse  der  Irren,  1880. — Mairet  et  Vires.  De  la 
paralysie  generate.  Etiologie.  Pathogenic  Traitement.  1893. — 
Magnan  et  Serieux.  La  paralysie  generate  (collection  Leaute), 
1894. — Coulon.  Considerations  sur  la  nature  de  la  paralysie  generate. 
— Klippel.  Les  paralysies  generates.  L'ceuvre  medico-chirurgicale, 
1898. 


GENERAL  PARESIS.  213 

These  symptoms  are,  however,  not  identical  with 
those  of  true  neurasthenia.  The  following  are,  accord- 
ing to  Ballet,  the  most  important  points  of  difference: 

"  (1;  The  stigmata,  that  is  to  say  the  permanent  signs 
of  neurasthenia  (helmet  sensation,  pain  in  the  spine), 
are  usually  absent. 

"  (2)  Neuralgic  pains  occupy  an  important  place  in 
the  clinical  picture.  These  pains  (excluding  the  lightning 
or  lancinating  pains  dependent  upon  the  spinal  lesions 
of  general  paresis)  are  disseminated,  essentially  mobile, 
varying  from  day  to  day.  The  patients  often  speak 
of  them  as  'pains  that  are  peculiar  and  unusual. ' 

"(3)  From  one  moment  to  another  sudden  changes 
are  produced  in  the  state  of  the  patient.  ...  It  is  sur- 
prising to  see  the  neurasthenic  paretic,  who  but  a  short 
time  before  complained  of  severe  suffering  and  ill  health, 
forget  his  pains  under  the  influence  of  some  incident 
or  conversation  in  which  he  is  interested  and  in  which 
he  takes  an  active  part.  These  momentary  changes, 
appearing  at  the  instance  of  chance  occurrences,  may 
manifest  themselves  in  a  more  lasting  manner  on  in- 
stituting some  treatment,  though  insignificant.  The 
patient,  hitherto  excessively  discouraged  and  gloomy, 
speaks  with  joy  of  his  cure;  his  satisfaction  is  exuberant 
and  out  of  proportion,  as  was  his  despair  shortly 
before." 

Often  some  transient  phenomenon,  exceptional  or 
unknown  in  neurasthenia,  alarms  the  physician:  slight 
seizures,  transitory  strabismus  with  diplopia,  slightly 
marked  momentary  disorders  of  speech. 

This  period  of  prodromata  is  seldom  absent.  It  is 
often  very  long,  lasting  several  months  or  even  years. 


214  MANUAL  OF  PSYCHIATRY. 

§  1.  Essential  Symptoms. 

It  will  be  necessary  to  consider  these  apart  from 
the  accessory  symptoms,  by  the  presence  of  which 
they  are  often  masked. 

The  essential  symptoms  are: 

(A)  Intellectual  enfeeblement; 

(B)  Disorders  of  motility; 

(C)  Pupillary  disturbances; 

(D)  Changes  in  the  general  nutrition. 

(A)  Intellectual  enfeeblement. — It  presents  two  fun- 
damental characteristics : 

(1)  It  affects  all  the  psychic  functions  in  their 
ensemble; 

(2)  It  is  progressive,  and  even  rapidly  so.  This 
latter  characteristic  distinguishes  paralytic  dementia 
from  senile  dementia,  the  development  of  which  is  much 
slower. 

Let  us  analyze  rapidly  the  elements  constituting 
this  intellectual  enfeeblement. 

(a)  Memory. — It  is  profoundly  affected  from  the  very 
beginning.  The  amnesia  is  both  anterograde,  by  default 
of  fixation,  and  retrograde,  by  destruction  of  impres- 
sions.    It  is  essentially  incurable. 

The  disappearance  of  old  impressions  probably  fol- 
lows the  law  of  retrogression;  but  its  course  is  so 
rapid  that  it  is  difficult  to  demonstrate  this  fact.  The 
impressions  of  youth  and  childhood  become  very 
rapidly  effaced,  so  that  after  a  relatively  short  period 
only  a  few  confused  and  distorted  recollections  remain 
in  the  mind  of  the  patient,  and  these  are  only  with 
great  difficulty  recovered  from  the  general  wreck. 


GENERAL   PARESIS.  215 

(b)  Consciousness  and  perception. — Their  disorders 
are  manifested  by: 

(I)  A  more  or  less  complete  loss  of  orientation  in  all 
its  forms; 

(II)  A  more  or  less  confused  perception  of  the  external 
world. 

The  clouding  of  consciousness  and  the  confusion 
attain  in  the  terminal  period,  and  in  certain  forms  in 
the  beginning,  an  extreme  intensity. 

(c)  Attention. — It  is  both,  difficult  to  obtain  and 
difficult  to  fix  the  attention. 

(d)  Associations  of  ideas. — These  are  always  sluggish 
and  easily  modifiable  by  external  impressions.  These 
disorders  render  it  impossible  for  the  patient  to  per- 
form somewhat  complicated  intellectual  operations,  or 
even  the  simplest  ones  in  advanced  cases  of  paresis. 

(e)  Affectivity.  —  Its  changes  are  characterized  by 
morbid  indifference  and  irritability,  associated  in  the 
manner  already  studied.  The  one  and  the  other  are 
very  marked.  The  general  paretic  takes  no  interest 
in  his  own  business  affairs  or  in  the  welfare  of  his 
relatives.  Grave  occurrences  fail  to  impress  him.  On 
the  other  hand,  he  is  subject  to  fits  of  terrible  anger 
on  the  slightest  provocation. 

The  moral  sense  and  the  regard  for  conventionalities 
disappear  entirely.  The  patient  commits  the  most 
ridiculous  and  most  revolting  acts  with  perfect  serenity 
and  is  astonished  when  his  liberty  of  action  is  interfered 
with. 

(/)  Judgment. — Its  disorder  finds  expression  in  the 
patient's  total  lack  of  insight  into  his  condition. 
Together  with  the  amnesia,  it  explains  the  inconsist- 


216  MANUAL  OF  PSYCHIATRY. 

encies  of  the  patient's  conduct  and  speech;  he  is 
unable  to  appreciate  the  most  flagrant  contradictions. 
To  a  given  question  the  paretic  gives  the  first  answer 
that  enters  his  mind,  whether  it  happens  to  be  false 
or  correct,  absurd  or  plausible. 

(g)  Reactions.  —  As  might  be  expected,  they  are 
always  impulsive.  The  reflections,  that  is  to  say  the 
series  of  associations  preceding  the  act,  become  more 
and  more  reduced.  As  the  patient  sees  what  he  wants 
he  immediately  takes  it.  He  wants  an  object  that 
he  sees  exposed  for  sale  in  a  shop, — he  takes  it  and 
carries  it  off  without  taking  the  trouble  to  pay  for  it. 
A  paralytic  leaning  over  the  parapet  of  a  bridge  drops 
his  cane.  To  recover  it,  reasoning  that  a  straight  line 
is  the  shortest  distance  between  two  points,  he  jumps 
after  it  into  the  water.  Stereotyped  movements 
(movements  of  sucking,  grinding  the  teeth,  etc.)  and 
negativism  are  frequent.  Cataleptoid  attitudes  are 
occasionally  seen. 

(B)  Motor  disturbances. — The  fundamental  motor 
disturbances,  the  only  ones  that  need  occupy  us  in  this 
connection,  are  three  in  number: 

(a)  Progressive  muscular  enfeeblement ;  (b)  Tremors; 
(c)  Motor  incoordination. 

(a)  Muscular  enfeeblement. — It  is  most  marked  in  the 
latter  periods  of  the  affection,  when  it  accompanies 
the  general  cachexia.  It  involves  all  the  muscles  and 
is  associated  with  a  more  or  less  pronounced  atrophy 
so  that  there  is  more  or  less  complete  disability. 

(b)  Tremors. — Unlike  the  muscular  enfeeblement, 
these  constitute  an  early  symptom.  They  are  of  two 
forms:   fibrillary  tremors  and  tremors  en  masse. 


GENERAL  PARESIS  217 

(I)  The  fibrillary  tremors  consist  in  rapidly  repeated 
contractions  of  very  small  groups  of  muscular  fibers. 
It  is  a  sort  of  twitching.  It  is  observed  chiefly  in  the 
tongue  and  in  the  peribuccal  muscles. 

(II)  Tremors  en  masse  usually  appear  as  coarse  oscil- 
lations irregular  in  frequency  and  in -amplitude.  They 
become  evident  on  voluntary  movements  and  form 
a  sort  of  point  of  transition  between  true  tremors  and 
muscular  ataxia.  They  are  seen  especially  in  the 
upper  extremities  and  in  the  tongue.  The  tongue  pro- 
jected from  the  mouth  executes  to-and-fro  movements 
very  aptly  called  by  Magnan  "  trombone  movements.' ' 

(c)  Motor  incoordination. — This  first  becomes  evident 
in  the  most  delicate  movements  and  manifests  itself 
early  by  impairment  of  the  speech  and  of  the  hand- 
writing. 

(a)  The  impairment  of  speech,  clearly  apparent  in 
advanced  stages,  is  sometimes  difficult  to  notice  at 
the  beginning  and  only  becomes  evident  on  resorting 
to  special  tests,  such  as  prolonged  reading  in  a  loud 
voice  or  the  pronunciation  of  special  words  known  as 
test-worcls:  Methodist  Episcopal,  fourth  cavalry  bri- 
gade, national  intelligence,  etc. 

Sometimes  the  impairment  of  speech  becomes  less 
evident  or  even  disappears  temporarily  during  excite- 
ment. Often  it  becomes  accentuated  after  apoplecti- 
form or  epileptiform  attacks. 

It  is  of  various  types,  the  principal  of  which  are  the 
following : 

I.  Drawling,  tremulous,  indistinct  speech; 

II.  Scanning  speech  analogous  to  that  of  dissemi- 
nated sclerosis; 


218  MANUAL  OF  PSYCHIATRY. 

III.  Hesitating  speech:  the  patient  stops  in  the 
middle  of  a  word  and  seems  to  hesitate  before  finishing 
it; 

IV.  Omission  of  one  or  of  several  syllables:  the 
patient  pronounces,  for  instance,  "Methist  Pispal" 
instead  of  Methodist  Episcopal; 

V.  Reduplication  of  one  or  of  several  syllables,  as 
constitititutional ; 

VI.  Interchanging  of  syllables:  " constutitional." 
These  types  may  be  combined  so  as  to  form  mixed 

types  of  infinite  varieties. 

(/?)  The  handwriting  is  characterized  by  its  irregular 
appearance,  and  by  the  coarse  tremors  seen  in  the 
strokes.  These  motor  disorders  are  always  associated 
with  phenomena  of  intellectual  origin:  omissions  or, 
on  the  contrary,  repetitions  of  letters,  syllables,  or 
words,  numerous  glaring  orthographical  errors.  All 
these  features  impart  to  the  paretic  handwriting  its 
characteristic  aspect. 

Usually  the  patient  is  totally  unconscious  of  these 
symptoms.  If  accidentally  he  notices  them,  he  is 
neither  surprised  nor  alarmed.  The  explanations  which 
he  gives  are  childish:  he  does  not  speak  well  because 
he  has  lost  a  tooth,  or  he  writes  with  difficulty  because 
his  hands  are  cold. 

Slight  in  the  beginning,  the  impediment  of  speech 
and  the  impairment  of  handwriting  become  progressively 
aggravated,  so  that  in  the  terminal  stage  of  the  disease 
the  writing  becomes  a  shapeless  scribbling  and  the 
speech  an  unintelligible  stammering. 

At  the  end  of  the  disease  it  is  almost  constant  to 
note  a  disturbance  of  deglutition  caused  b}^  paresis  and 


GENERAL  PARESIS.  219 

incoordination  of  the  pharyngeal  muscles,  which  may 
entail  death  by  suffocation. 

(C)  Pupillary  disorders. — Appearing  sometimes  very 
early,  their  importance  is  so  great  that  in  their  absence 
the  diagnosis  should  always  be  reserved.1 

They  are  dependent  upon  an  internal  ophthalmoplegia 
of  gradual  and  progressive  development  (Baillet  and 
Bloch),  which  is  manifested  by  changes  in  the  shape, 
size,  and  reactions  of  the  pupil. 

(a)  Changes  in  the  shape. — The  pupil  loses  its  circular 
shape  and  becomes  oval  or  irregular.  This  symptom 
seems  to  be  frequent,  but  of  its  diagnostic  value  little 
is  known. 

(b)  Changes  in  size, — These  are  of  three  kinds: 

(I)  Myosis,  at  times  so  marked  that  the  pupils  are 
reduced  to  pin-hole  size; 

(II)  Mydriasis,  also  very  well  marked  in  certain 
cases; 

(III)  Inequality  of  the  pupils,  which  may  be  pro- 
duced by  three  different  mechanisms: 

(a)  One  pupil  is  normal,  the  other  myotic  or  mydri- 
atic; 

(/?)  One  pupil  is  mydriatic,  the  other  myotic; 

(y)  Both  pupils  are  mydriatic  or  myotic,  but  are 
unequally  dilated  or  contracted. 

It  is  important,  in  order  to  make  a  satisfactory  exam- 
ination of  the  pupils,  to  place  the  patient  in  such  a 
light  that  both  eyes  receive  an  equal  amount  of  illu- 


1  Mignot.     Contribution  a  V etude  des  troubles  pupillaires  dans  quel- 
c/ues  maladies  mentales.    These  de  Paris,  1900. 


220  MANUAL  OF  PSYCHIATRY. 

mination.  It  is  also  important  to  vary  the  intensity 
of  illumination,  because  an  inequality  that  appears 
doubtful  in  a  strong  light  may  become  very  evident  in 
a  weaker  light,  and  vice  versa. 

Pupillary  inequality  is  sometimes  congenital.  More- 
over, it  is  encountered  in  many  affections  other  than 
general  paresis:  dementia  precox,  compression  of  the 
sympathetic  nerve,  etc.;  therefore  it  does  not  by 
any  means  constitute  a  pathognomonic  sign. 

(c)  Changes  in  the  reflexes. — These  consist  in  changes 
of  the  light  reflex,  or  of  the  accommodation  reflex,  or  of 
both.     They  are  either  binocular  or  monocular. 

Disorders  of  the  pupillary  reactions  may  be  associated 
as  in  the  Argyll-Robertson  type:  abolition  of  the  light 
reflex  with  persistence  of  the  accommodation  reflex. 
This  combination  is,  however,  considerably  less  frequent 
in  paresis  than  it  is  in  tabes. 

At  the  beginning  of  the  disease  the  reactions  are 
not  completely  abolished,  but  are  simply  paretic. 

(D)  Disorders  of  general  nutrition. — Though  constant 
and  very  important  they  have  thus  far  received  but 
little  attention.  Clinically  we  find  changes  in  the 
weight  and  in  the  urinary  secretion. 

The  onset  is  almost  always  marked  by  a  considerable 
loss  of  weight.  Later  the  weight  varies  with  the  clinical 
form. 

In  the  excited  and  in  the  depressed  forms  of  rapid 
evolution  the  loss  of  weight  is  marked  and  progressive, 
and  the  patient  rapidly  becomes  cachectic. 

In  the  expansive  or  demented  forms  the  weight  often 
rises  after  the  initial  fall,  the  patients  then  becoming 
corpulent  and  remaining  so  until  the  terminal  stage, 


GENERAL  PARESIS.  221 

when  the  weight  may  fall  suddenly  and  continue  to  drop 
as  marasmus  is  established. 

Organic  crises  may  be  noted  in  the  course  of  the 
disease  (Arnaud);  they  consist  in  a  transitory  but  con- 
siderable loss  of  weight,  the  cause  of  which  is  unknown. 

The  changes  in  the  urinary  secretion  indicate  a 
general  sluggishness  of  nutrition.  They  have  been 
especially  studied  in  connection  with  the  second  period 
of  the  disease.  The  principal  ones  are  polyuria,  low 
specific  gravity  of  the  urine,  slight  albuminuria,  a  very 
noticeable  diminution  of  urea  and  of  phosphates,  and 
an  increase  of  chlorides.1 

A  study  of  the  blood  changes  might  also  be  of  great 
interest.  The  work  already  done  along  this  line  is 
unfortunately  very  little  and  inconclusive.  Capps2 
found  a  slight  diminution  of  hemoglobin  and  of  the 
red  blood-cells. 

§  2.  Inconstant  Symptoms. 

Many  symptoms  though  not  constant  are,  however, 
frequent  and  important. 
This  group  comprises: 

(A)  Intellectual  disorders; 

(B)  Motor  disorders; 

(C)  Disorders  of  the  reflexes; 

(D)  Disorders  of  sensation; 

(E)  Trophic  disorders; 

1  Klippel  et  Serveaux.  Contribution  a  V etude  de  Vurine  dans  la 
paralysie  generate.  Congres  des  medecins  alienistes  et  neurologistes, 
1895. 

2  American  Journ.  of  the  Med.  Sc.,  1896,  No.  290. 


222  MANUAL  OF  PSYCHLATRY. 

(F)  Visceral  disorders; 

(G)  Epileptiform  and  apoplectiform  seizures. 

(A)  Intellectual  disorders. — The  principal  are  delu- 
sions and  hallucinations. 

(a)  The  delusions  of  the  general  paretic  are  of  the  de- 
mented type;  that  is  to  say,  they  are  absurd,  mobile, 
multiple,  and  contradictory. 

They  assume  all  forms: 

(a)  Ideas  of  grandeur:  the  patient  is  immensely  rich; 
millions  are  not  adequate,  the  general  paretic  counts 
his  riches  by  trillions;  he  governs  the  forces  of  nature, 
resuscitates  the  dead,  is  the  incarnation  of  all  the  great 
men  of  the  present  or  of  the  future,  destroys  and  recon- 
structs the  universe  by  a  single  gesture,  etc. 

(/?)  Melancholy  ideas:  ideas  of  culpability:  one  pa- 
tient accused  himself  of  having  hastened  the  end  of 
the  world  by  ten  thousand  centuries;  hypochondriacal 
ideas:  another  patient  refused  to  eat  because  he  had  "  a 
bicycle  manufactory  in  the  throat";  ideas  of  negation: 
the  organs  are  liquefied  or  replaced  by  air,  the  body  is 
nothing  but  a  putrefied  corpse;  ideas  of  ruin  analogous 
to  those  of  melancholia. 

(r)  Persecutory  ideas:  they  are  either  primary  or 
secondary  to  ideas  of  grandeur.  In  the  latter  case  the 
patients  complain  that  they  have  been  robbed  of  their 
immense  fortune,  that  they  are  not  treated  with  the 
respect  to  which  they  are  entitled,  that  they  are  unjustly 
detained  in  the  asylum,  etc.  Occasionally  at  the 
beginning  persecutory,  ideas  become  systematized,1  but 
always  imperfectly.     A  close  examination  always  reveals 

1  Magna)].     Lemons  cliniques, 


GENERAL  PARESIS.  223 

certain  flagrant  contradictions  by  which  the  intellectual 
enfeeblement  manifests  itself. 

(b)  The  frequency  of  hallucinations  in  general  paresis 
is  a  much  disputed  question.  Some  authors  believe 
that  they  are  almost  constant  (Christian  and  Ritti),  or 
at  least  frequent  (Wernicke);  others  claim  that  they 
are  rare  (Magnan,  Dagonet,  Krafft-Ebing) .  The  latter 
opinion  is  the  more  widely  accepted  one  and  I  believe 
the  more  correct  one. 

The  hallucinations  may  affect  any  of  the  senses, 
including  the  muscular  sense. 

Illusions  are  much  more  frequent  than  hallucina- 
tions. 

Psycho-sensory  disorders  are  encountered  chiefly  in 
the  excited  form  of  general  paresis,  in  which  they  are 
associated  with  incoherent  delusions. 

The  systematized  persecutory  delusions  which  are 
occasionally  met  with  are  apt  to  be  associated  with 
auditory  hallucinations. 

As  in  all  cases  of  pronounced  dementia,  the  reactions 
and  the  emotional  tone  do  not  always  harmonize  with 
the  delusions.  A  general  paretic  who  believes  himself 
to  be  dead  may  eat  heartily  and  remain  otherwise 
unaffected. 

(B)  Motor  disorders. — The  most  frequent  are  the 
phenomena  of  paralysis  and  of  paresis,  which  may  assume 
the  most  varied  types:  monoplegia,  hemiplegia,  facial 
paralysis.  The  latter,  generally  slight,  constitutes  a 
very  frequent  and  often  an  early  symptom. 

The  paralysis  is  either  flaccid  or  associated  with 
contractures. 

A  certain  degree  of  motor  aphasia  is  often  observed. 


224  MANUAL  OF  PSYCHIATRY. 

The  paralyses  in  many  cases  follow  the  seizures 
and  are  usually  transitory. 

Convulsions  will  be  considered  in  connection  with 
the  epileptiform  seizures. 

Sometimes  choreiform  movements  are  observed  in 
general  paresis  (Vallon  and  Marie),  also  tremors  analo- 
gous to  those  of  multiple  sclerosis  and  of  athetosis. 

(C)  Disorders  of  the  reflexes. — The  best  known  and 
the   most   important   are  the    changes    in  the  patellar, 
reflex. 

There  is  nothing  constant  about  these,  as  they  vary 
not  only  in  different  patients  but  also  in  the  same 
patient  at  different  times. 

The  patellar  reflexes  may  be  normal,  exaggerated, 
diminished,  or  abolished.  Sometimes  they  are  unequal 
on  the  two  sides:  one  may  be  exaggerated,  the  other 
abolished. 

Complete  abolition  is  seen  in  the  tabetic  form,  exag- 
geration in  the  spastic  form. 

Other  tendon  reflexes  have  been  but  little  studied. 

As  to  cutaneous  reflexes,  they  are  sometimes  exag- 
gerated, more  often  abolished. 

(D)  Disorders  of  sensation. — These  have  been  well 
described  by  Marandon  de  Montyel,  from  whom  the 
following  facts  have  been  borrowed: 

(a)  Sensibility  to  pain  is  often  diminished,  less  fre- 
quently abolished,  rarely  exaggerated.  Some  patients 
present  retardation  of  the  perception  of  pain.  Dis- 
orders of  the  pain  sensibility  often  persist  during  remis- 
sions. 

(b)  Tactile  sensibility  is  usually  normal.  However 
there  may  be  hyperesthesia,  hyposesthesia,  and  even 


GENERAL  PARESIS.  -225 

complete  anaesthesia.  These  disorders  disappear  during 
remissions. 

(c)  Special  senses:  disorders  of  hearing  (more  or  less 
marked  deafness,  tinnitus,  etc.)  are  not  infrequent,  but 
by  reason  of  their  common  occurrence  in  other  forms 
of  insanity  and  in  normal  individuals  they  are  of  but 
slight  importance. 

Amblyopia  or  even  complete  amaurosis  is  sometimes 
encountered.  In  certain  cases  it  depends  upon  an 
atrophy  of  the  optic  nerve. 

The  senses  of  taste  and  smell  are  often  greatly 
impaired. 

Disorders  of  the  generative  function  are  quite  frequent 
and  vary  with  the  stage  of  the  disease. 

The  onset  is  often  marked  by  genital  excitation,  which, 
associated  with  the  mental  enfeeblement,  may  lead  to 
grave  consequences.  Later  this  excitation  is  replaced 
by  absolute  impotence. 

(E)  Trophic  disorders. — These  affect  all  the  tissues. 

Osseous  tissue:  abnormal  fragility  of  the  bones, 
fractures  caused  by  insignificant  traumatisms  or  even 
occurring  spontaneously. 

Connective  and  cartilaginous  tissues:  the  trophic 
disorders  are  here  chiefly  manifested  by  hematoma 
auris,1  which  consists  in  an  extravasation  of  blood 
into  the  tissues  of  the  auricle. 

The  exact  seat  of  the  extravasation  in  hsematoma 
auris  is  still  a  disputed  question.  Some  are  of  the 
opinion  that  it  is  in  the  subcutaneous  tissues,  others 


1  Gatian  de  Clerambault.     Contribution  a  V  etude  de  Vothematome. 
These  de  Paris,  1899. 


226  MANUAL  OF  PSYCHIATRY. 

believe  that  it  is  between  the  cartilage  and  the  peri- 
chondrium, and  still  others  think  that  it  is  within  the 
cartilage  itself. 

The  action  of  the  trophic  disorder  is  usually  favored 
by  a  traumatism.  It  must  not  be  forgotten  that  the 
great  majority  of  hsemotomata  auris  are  on  the  left 
side  and  that  when  one  receives  a  blow  it  is  usually 
just  on  that  side.  It  is  possible  to  reduce  considerably 
the  number  of  hsemotomata  in  asylums  by  holding 
the  attendants  directly  responsible  for  their  occurrence. 

Skin. — Deformity  and  grooving  of  the  nails/  diverse 
eruptions,  herpes.  The  latter  lesion  indicates  involve- 
ment of  the  cord  in  the  pathological  process;  it  may 
constitute  one  of  the  first  symptoms  of  the  disease. 

The  most  frequent  and  most  grave  cutaneous  dis- 
turbances are  the  pressure-sores. 

Whether  bilateral  or  unilateral  they  develop  chiefly 
at  the  points  bearing  the  weight  of  the  body  while 
the  patient  is  in  bed:  hence  the  sacral,  gluteal,  and 
trochanteric  bed-sores.  The  sacral  bed-sore  is  quite 
often  median. 

Their  dimensions  vary  from  small  sores  of  the  size  of 
a  dime  to  those  exceeding  the  size  of  the  palm  of  the 
hand. 

Their  depth  also  varies  in  different  cases.  Some 
remain  superficial,  while  others  destroy  the  skin,  sub- 
cutaneous tissue,  and  muscles,  and  expose  the  bone. 

Their  course  is  usually  progressive ;  that  is  to  say,  they 
increase  in  extent  and  in  depth.  Sometimes  they  heal 
under  the  influence  of  appropriate  treatment. 

1  Treves.  Su  alcani  alteretzioni  distrophiche  delle  unghi.  Rivist. 
di  clin.  medic,  1899,  No.  6. 


GENERAL  PARESIS.  227 

Muscles. — Localized  muscular  atrophy  is  rare.  It 
affects  different  groups  of  muscles  and  may  have  one 
of  two  origins,  resulting  either  from  a  degeneration  of 
the  white  columns  of  the  cord,  which,  in  its  turn,  is 
caused  by  cerebral  lesions  (Grelliere),1  or  from  a 
primary  degeneration  of  the  cells  in  the  anterior  horns 
(Joffroy).2 

(F)  Visceral  disorders. — These  are  dependent  either 
upon  the  disease  itself  or  upon  a  complication.  It  is 
unfortunately  difficult  to  determine  in  any  given  case 
what  the  real  cause  is. 

(a)  Digestive  apparatus:  its  functions  become  dis- 
turbed chiefly  in  the  terminal  stage  of  all  forms,  and 
early  in  the  depressed  and  excited  forms:  anorexia, 
vomiting,  constipation,  or  intractable  diarrhoea.  In 
the  expansive  form  one  often  notes  a  veritable  boulimia. 

(b)  Cardio-vascular  apparatus:  Evidences  of  atheroma, 
myocarditis,  rapid  and  feeble  pulse  in  the  terminal 
cachexia.  Aortic  insufficiency  is  not  rare  and  is  prob- 
ably due  to  syphilis,  which  is  so  frequent  in  the  history 
of  general  paretics. 

(c)  Kidneys:  Slight  albuminuria  is  frequent.  This 
with  the  low  specific  gravity  of  the  urine  is  an  indica- 
tion of  a  certain  degree  of  renal  insufficiency. 

(d)  Liver:  Sometimes  hypertrophied,  more  rarely 
atrophied  with  phenomena  of  cirrhosis.  The  ascites 
that  usually  accompanies  atrophic  cirrhosis  of  the  liver 


1  Grelliere.     Atrophie  musculaire  dans  la  paralysie  generate  des 
alienes.     Paris,  1875 

2  Joffroy      Contribution  a  Vanatomie  pathologique  de  la  paralysie 
generate.     Congres  de  Medecine  mentale,  1892. 


228  MANUAL  OF  PSYCHIATRY. 

is  usually  absent  in  the  cirrhosis  of  general  paresis 
(Klippel). 

(e)  Respiratory  apparatus:  Congestion,  broncho- 
pneumonia, and  splenization  are  frequent  complica- 
tions of  the  last  stage.  Pulmonary  tuberculosis  is, 
on  the  contrary,  quite  rare  and  usually  runs  a  slow 
course  (Bergonier,  Klippel). 

(G)  Seizures.1 — These  are  frequent,  occurring  at  all 
periods  of  the  disease  and  often  marking  the  onset. 
They  may  be  fatal.  According  to  Arnaud  death  from 
a  seizure  is  the  natural  mode  of  termination  of  general 
paresis.     They  are  often  accompanied  by  fever. 

On  recovery  from  these  seizures,  which  is  most  usual, 
symptoms  of  apoplexy  (paralysis,  aphasia)  often  appear ; 
they  are  almost  always  transitory,  there  being  no  gross 
lesions  of  the  corresponding  projection-center.  The 
seizures  are  generally  followed  by  an  aggravation  of 
the  fundamental  psychical  and  physical  disorders. 

The  seizures  are  of  two  kinds:  apoplectiform  or  epi- 
leptiform. 

The  former  are  characterized  by  a  more  or  less  com- 
plete loss  of  consciousness  associated  with  complete 
flaccidity  of  the  limbs. 

The  latter  consist  in  generalized  or  localized  convulsions. 
The  generalized  convulsions  sometimes  so  closely  sim- 
ulate epilepsy  as  to  be  mistaken  for  it.  The  localized 
convulsions  assume  the  aspect  of  Jacksonian  epilepsy 
(monocrural,  monobrachial,  facial).     The  loss   of  con- 


1  Pierret.  Les  attaques  epileptiformes  et  apoplecti formes  dans  la 
paralysie  generate.  Progres  medical,  1897. — Arnaud.  Arch,  de 
neural,  1897. — Bonnat.     These  de  Paris,  1900. 


GENERAL  PARESIS.  229 

sciousness  accompanying  the  partial  convulsions  is 
either  complete  or  reduced  to  a  slight  degree  of  obnubila- 
tion, as  in  the  case  of  the  sympathetic  convulsions  of 
apoplexy  or  of  cerebral  tumor. 

§  3.  Forms.    Evolution.    Diagnosis. 

The  principal  forms  are: 

(A)  The  demented  form; 

(B)  The  expansive  form; 

(C)  The  excited  form; 

(D)  The  melancholic  form; 

(E)  The  tabetic  form. 

Some  authors  have  described  also  a  spastic  form,, 
characterized  by  exaggeration  of  the  tendon  reflexes  and 
by  muscular  contractures. 

A.  The  demented  form. — This  form  constitutes  from 
a  psychical  standpoint  of  view  the  pure  type  of  gen- 
eral paresis,  free  from  accessory  symptoms. 

The  onset  is  marked  chiefly  by  indifference  and  loss  of 
memory. 

When  the  disease  is  completely  established  the  symp- 
toms are  those  of  profound  mental  enfeeblement,  which 
we  have  already  described,  associated  with  the  charac- 
teristic physical  disorders. 

This  form  is  frequent;  its  evolution  is. rapid  and  not 
interrupted  by  remissions. 

B.  The  expansive  form. — Also  frequent. 
Special  features: 

Euphoria,  often  very  marked. 

Effusions  of  benevolence,  interrupted  by  transitory 
outbreaks  of  anger. 


230  MANUAL  OF  PSYCHIATRY. 

Ideas  of  self-satisfaction  and  ideas  of  grandeur  (hallu- 
cinations are  very  rare). 

Excitement,  loquaciousness. 

The  disease  begins  with  a  morbid  activity  and  slight 
excitement,  which,  associated  with  disorders  of  judgment, 
often  lead  the  patient  to  ruinous  deeds,  misdemeanors, 
and  even  crimes.  Unnecessary  purchases,  absurd  enter- 
prises, violations  of  decency,  rape,  and  swindling  are 
common.  It  is  this  stage  that  constitutes  chiefly  the 
medico-legal  period  of  general  paresis. 

The  evolution  of  this  form  is  slow.  The  duration 
of  the  illness  quite  frequently  exceeds  three  years. 
Remissions  are  frequent. 

C.  The  excited  form.  —  This  sometimes  begins  with 
a  state  of  excitement  and  confusion  resembling  mania 
or  acute  confusional  insanity. 

Its  special  features  are: 

Complete  disorientation  in  all  its  forms; 

Incoherent  delusions,  usually  associated  with  numer- 
ous hallucinations ; 

Violent  reactions  with  very  marked  motor  excitement ; 

Profound  disturbances  of  the  general  nutrition. 

It  may  run  one  of  two  possible  courses:  the  excite- 
ment may  persist  and  death  supervene  within  a  few 
months  or  even  weeks  (galloping  general  paresis);  or 
the  excitement  may  subside  and  the  disease  may  pass 
into  one  of  the  other  forms,  the  demented,  expansive, 
or  melancholic. 

D.  Melancholic  form. — The  onset  is  marked  by  a 
state  of  depression  or  of  moral  pain,  so  that  the  trouble 
may  be  mistaken  for  affective  melancholia  or  for  an 
attack  of  manic  depressive  insanity. 


GENERAL   PARESIS.  231 

The  special  features  of  this  form  are: 

Psychic  inhibition; 

Moral  pain ; 

Melancholic  delusions ; 

Attempts  at  suicide  that  are  frequently  childish  and 
ineffective ; 

Peripheral  vaso-constriction,  impairment  of  the  gen- 
eral nutrition. 

Refusal  of  food. 

All  these  disorders,  however,  harmonize  less  perfectly 
with  each  other  than  in  the  other  melancholic  affections.  I 
shall  return  to  this  point  in  connection  with  the  diagnosis. 

The  evolution  is  very  rapid.  Death  supervenes  early, 
and  is  due  to  the  cachexia  or  to  some  complication 
(infections  favored  by  the  impaired  nutrition  and  the 
diminished  resistance  of  the  tissues). 

E.  Tabetic  form. — This  form  has  at  the  beginning 
the  aspect  of  ordinary  tabes.  The  signs  of  general 
paresis  appear  much  later. 

Its  special  features  are: 

Lightning,  lancinating  pains;   girdle  sensation; 

Marked  ataxic  symptoms; 

Abolition  of  patellar  reflexes; 

Romberg's  symptom; 

Argyll-Robertson  pupil. 

The  symptomatology  of  this  form  of  general  paresis 
is,  however,  not  identical  with  that  of  true  tabes.  The 
pains  are  less  severe,  the  urinary  troubles  less  frequent 
(Joffroy).  A  curious  fact  difficult  to  explain  is  that 
as  the  symptoms  of  general  paresis  become  more  pro- 
nounced, those  of  tabes  (at  least  the  subjective  symp- 
toms) seem  to  disappear. 


232  MANUAL  OF  PSYCHIATRY. 

The  different  forms  above  mentioned  may  follow 
each  other,  or  they  may  be  associated  in  the  most  varied 
ways. 

Course  and  prognosis. — The  course  is  progressive, 
and  has  been  schematically  divided  into  three  stages, 
not  including  the  prodromal  stage:  (1)  stage,  of  onset; 
(2)  stage  of  complete  development;  (3)  stage  of 
cachexia. 

The  last  stage,  the  only  one  which  has  so  far  remained 
unquestioned,  is  characterized  by  complete  physical 
and  psychical  dilapidation,  by  the  appearance  of  pres- 
sure-sores, and  by  entire  loss  of  sphincter  control. 

The  prognosis  is  fatal.  Death  occurs  from  cachexia, 
or  from  some  complication,  or  as  the  result  of  an 
apoplectiform  or  epileptiform  seizure. 

The  average  duration  of  the  disease  is  from  two  to 
three  years.  There  is,  however,  no  fixed  rule  with 
regard  to  this.  In  exceptional  cases  the  disease  lasts 
but  several  months  or  even  weeks  (galloping  general 
paresis) ;  in  other  cases,  on  the  contrary,  it  is  prolonged 
for  ten  or  more  years. 

The  progress  of  the  disease  may  be  interrupted  by 
remissions.  Rarely,  except  at  the  beginning,  are  the 
remissions  complete.  Almost  always  a  certain  degree 
of  mental  enfeeblement  or  at  least  of  psychic  asthenia, 
and  the  persistence  of  the  physical  signs  exclude  all 
thought  of  true  recovery. 

Diagnosis. — The  fundamental  element  of  the  diagnosis 
is  the  association  of  the  progressive  intellectual  enfeeble- 
ment en  masse  with  the  characteristic  physical  signs. 

General  paresis  may,  especially  at  the  beginning, 
when   neither   the    intellectual   enfeeblement    nor    the 


GENERAL  PARESIS.  233 

somatic  signs  are  very  marked,  simulate  many  other 
psychoses. 

Lumbar  puncture  is  here  of  great  service.  An  in- 
crease in  the  number  of  leucocytes  in  the  cephalo- 
rachiclian  fluid  is  an  almost  constant  phenomenon  of 
general  paresis,  especially  at  the  onset.  Though  it 
never  appears  in  the  absence  of  meningeal  lesions,  its 
presence  eliminates  the  vesanias  as  well  as  the  dementias 
dependent  upon  central  organic  lesions  without  menin- 
geal involvement,  such  as  senile  dementia,  for  instance, 
(Dupre).1 

Mania.2 — Flight  of  ideas  and  continued  excitement 
are  characteristic.  Lucidity  is  usually  preserved  or, 
at  any  rate,  much  less  affected  than  in  general  paresis; 
delusions  are  less  frequent  and  less  absurd. 

Affective  melancholia;  depressed  form  of  manic 
depressive  insanity. — The  essential  symptoms  (moral 
pain  or  psychic  inhibition)  are  much  more  stable. 
The  delusions  are  less  ridiculous  and  less  incoherent, 
and  are  much  more  in  harmony  with  the  state  of  the 
affectivity  and  with  the  reactions. 

The  general  paretic  may  show  almost  no  moral  pain 


1  Levi  Sirugue.  Gazette  des  hopitaux,  1900,  No.  111. — Dupre  et 
Devaux.  Cytodiagnostic  cephalo-rachidien  dans  les  maladies  men- 
tales.  Bulletins  et  memoires  de  la  Societe  medicale  des  hopitaux 
de  Paris,  June  7,  1901. — Joffroy  et  Mercier.  De  Vutilite  de  la 
ponction  lombaire  pour  le  diagnostic  dans  la  paralysie  generate. 
Congres  des  medecins  alienistes  et  neurologistes,  12e  Session, 
Grenoble,  1902. 

2  Bonfigli.  C ontribuzione  alio  studio  delle  diagnosi  fra  paralizi 
progressive  e  folia  doppia  forma.  Rivista  sperimentale  di  neuropath, 
et  di  psych.,  1800. — Sprengler.  Zur  Fruhdiagnose  and  Therapie 
der  progressiven  Paralyse.     Allg.  Zeitschr.  f.  Psychiat.,  1901. 


234  MANUAL  OF  PSYCHIATRY. 

or  inhibition  in  spite  of  the  most  frightful  delusions. 
A  true  case  of  melancholia  or  of  manic  depressive 
insanity  never  presents  this  striking  contradiction 

Acute  conjusional  insanity. — The  onset  is  much  more 
sudden,  incoherence  and  disorientation  are  very  marked, 
but  there  is  absence  of  true  intellectual  enfeeble ment. 

Dementia  prcecox.1 — The  elective  character  of  the 
intellectual  enfeeblement  with  relative  conservation 
of  memory  and  lucidity.  Catatonic  phenomena  more 
constant,  more  numerous,  and  more  marked.  Difference 
in  the  etiology  (age  of  the  patient). 

Delirium  tremens. — This  may  be  simulated  by  the 
attacks  of  hallucinatory  delirium  which  are  apt  to 
appear  in  the  course  of  general  paresis.  Delirium 
tremens  is  recognized  by  the  intact  autopsychic  orienta- 
tion contrasting  with  complete  allopsychic  disorien- 
tation, by  the  different  physical  signs,  and  finally  by 
the  sudden  onset  which  is  never  seen  in  general  paresis. 

It  should  be  borne  in  mind  that  alcoholism  and  all 
its  manifestations  may  be  associated  with  general 
paresis.  In  all  such  cases  it  is  necessary  to  wait  for 
the  disappearance  of  the  acute  symptoms  before  the 
diagnosis  can  be  established. 

Alcoholic  dementia. — It  is  not  progressive  unless  the 
cause, — alcoholic  intoxication, — continues  to  act. 

Saturnine  encephalopathy. — This  disease  shows  a  fixed 
and  constant  localization  of  the  disorders  of  motion 
and  sensation,  which  is  seldom  encountered  in  general 
paresis.     Moreover,    when   further   absorption   of  lead 


1  Toulouse  et  Marchand.     Demence  precoce  et  paralysie  generate. 
R,evue  de  psychiat.,  1901,  No.  1. 


GENERAL   PARESIS.  235 

is  prevented,  the  symptoms  simulating  general  paresis 
become  less  marked  or  at  least  cease  to  progress.1 

PATHOLOGICAL   ANATOMY. — ETIOLOGY. — TREATMENT. 

We  shall  describe  separately  the  lesions  of  the  en- 
cephalon,  of  the  spinal  cord,  of  the  peripheral  nerves, 
and  of  the  viscera. 

A.  Encephalon.  —  Dura  mater:  often  congested,  pre- 
senting occasionally  the  lesions  of  hemorrhagic  pachy- 
meningitis. 

Pia-arachnoid  and  brain. 

(a)  Macroscopic  lesions. 

-(I)  General  atrophy  of  the  brain,  most  marked  in  the 
frontal  and  parietal  lobes,  and  evidenced  by: 

a.  Flattening  of  the  convolutions; 

/?.  Thinning  of  the  cortex; 

y.  Diminution  of  the  weight,  most  marked  in  cases 
of  slow  evolution,  often  very  slight  or  even  absent  in 
cases  of  general  paresis  of  a  very  rapid  course. 


1  By  the  term  general  pseudo-paresis  have  been  designated  affec- 
tions resulting  from  various  causes  and  simulating  more  or  less 
closely  true  general  paresis.  Thus  syphilitic,  alcoholic,  and  satur- 
nine pseudo-pareses  have  been  described.  This  term  is  a  useless 
one  and  its  use  has  been  abandoned  by  many  authors.  It  seems 
that  cases  often  described  as  those  of  general  pseudo-paresis  may 
be  cases  either  of  true  general  paresis  brought  on  by  syphilis, 
alcoholism,  lead-poisoning,  etc.,  or  of  cerebral  affections  of  syphilitic, 
alcoholic,  or  saturnine  origin,  and  of  a  symptomatology  analogous 
to,  but  not  identical  with,  true  general  paresis.  What  Magnan  said 
with  especial  reference  to  alcoholic  pseudo-paresis  holds  good,  I 
think,  for  the  entire  conception  of  pseudo-paresis :  It  is  not  borne 
out  by  clinical  experience;  moreover,  chronic  alcoholism  usually 
leads  to  dementia,  and  sometimes  to  true  general  paresis." 


236  MANUAL  OF  PSYCHIATRY. 

(2)  Thickening  of  the  pia  mater  and  adhesions  between 
it  and  the  cerebral  substance:  stripping  off  the  pia  causes 
a  tearing  away  of  the  cerebral  substance,  especially 
at  the  frontal  and  parietal  lobes. 

(3)  Arteritis  of  the  large  and  medium-sized  cerebral 
vessels:    this  lesion  is  not  a  constant  one. 

(b)  Microscopic  lesions.1 

(1)  Cells. — Their  changes  are: 

a.  In  number  and  arrangement:  many  cells  disap- 
pear; the  different  layers  are  more  difficult  to  distin- 
guish than  in  the  normal  state  and  appear  to  be  con- 
founded; 

/?.  In  shape:  the  processes  disappear,  the  angles 
become  blunted,  the  cell-body  tends  to  reduce  itself 
to  a  small  granular  and  pigmented  mass; 

y.  In  structure:  chromatolysis — that  is,  alteration 
and  destruction  of  NissPs  corpuscles — which  causes  the 
cell  to  assume  a  hyaline  aspect  when  the  chromatic 
substance  is  destroyed,  or  to  present  a  uniform  colora- 
tion if  stained  by  the  aniline  pigments  when  this  sub- 
stance, reduced  to  a  fine  powder,  is  disseminated  through 
the  entire  cell. 

(2)  Nerve-fibers:  many  are  destroyed,  which  fact  can 
be  demonstrated  by  Pal's  or  "Weigert's  hematoxylin 
stain.  The  degeneration  affects  chiefly  the  association 
fibers,  and  more  particularly  the  superficial  tangential 
fibers  of  Exner-Tuckzek. 


1  Ballet.     Les  lesions  cerebrates   de    la    paralysie   generate.     Ann 
mcd.     psych.,     1S98. — Anglade.     Sur    les    alterations    des    cellules 
nerveuses  dans  la  paralysie  generate.     Ann.  nu'd.  psych.,  Jul}- Aug. 
1898. 


GENERAL  PARESIS.  237 

(3)  Pia  mater  and  blood-vessels: 

a.  The  pia  mater  is  thickened,  infiltrated  by  nuclei 
representing  proliferating  fixed  connective-tissue  cells 
or  migrating  leucocytes. 

p.  The  blood-vessels  are  much  more  numerous  than 
normally;  the  walls  are  thickened,  often  showing  hya- 
line or  fatty  degeneration;  the  perivascular  spaces  are 
infiltrated  with  leucocytes.  The  appearance  of  these 
lesions  is  identical  with  those  of  diffuse  cerebral  syphilis.1 

(4)  Neuroglia. — Proliferation  of  the  neuroglia-cells  is 
very  frequently  seen ;  when  well  marked  it  is  especially 
prominent  in  the  vicinity  of  the  blood-vessels  (Mahaim) . 
Scantily  distributed  here  and  there  may  be  seen 
spider-cells  of  abnormal  shape  and  even  of  gigantic 
size. 

Which  of  the  above  lesions  are  primary?  There  are 
two  current  opinions,  as  follows: 

Some  (Joffroy,  Binswanger)  believe  that  the  lesions 
begin  in  the  tissues  of  higher  development, — the  nerve 
cells  and  fibers;  the  proliferation  of  neuroglia,  the 
increase  in  the  number  of  blood-vessels,  and  the  changes 
in  their  walls  are  secondary. 

Others  (Magnan,  Mendel,  Fournier)  are  of  the  opinion 
that  the  lesions  in  the  blood-vessels  are  primary  and 
those  of  the  higher  tissue  elements  secondary.  Ballet, 
though  adhering  to  this  opinion,  does  not  deny  that  in 
some  cases  of  rapid  evolution  the  changes  in  the  nerve- 
cells  may  be  primary. 

(B)  Spinal  cord.  —  (1)  Cells:  degenerative  and 
atrophic  lesions  identical  with  those  of  the  cerebral  cells. 

1  Mahaim.  De  V  importance  des  lex  ions  vasculaires,  etc.  Bullet, 
de  VAcad.  roy.  de  Med.  de  Belgique,  July  1901, 


238  MANUAL  OF  PSYCHIATRY. 

(2)  Nerve-fibers:  there  are  two  principal  types  of 
lesions, — the  tabetic  type  and  the  type  of  combined 
sclerosis. 

(a)  Tabetic  type. — The  degeneration  is  localized  in 
the  posterior  columns  and  is  similar  to  the  lesion  of 
tabes;  this  has  led  many  authors  to  look  upon  general 
paresis  and  tabes  as  two  different  localizations  of  the 
same  morbid  process.1 

An  examination  of  many  sections,  however,  shows 
that  the  lesions  of  the  posterior  columns  are  not  strictly 
systemic,  as  they  are  in  tabes.  According  to  Rabaud  2 
they  are  characterized  in  general  paresis: 

"  a.  By  their  irregularity,  which  is  seen  from  an 
examination  of  sections  from  different  levels  of  the 
cord; 

"/?.  By  their  diffuseness,  apparent  in  a  single  section 
of  the  cord; 

"  r.  By  the  frequent  coexistence  of  spinal  scleroses 
with  an  intact  condition  of  the  roots  and  of  the  zones 
of  Lissauer." 

It  seems,  then,  that  one  is  justified  in  looking  upon 
general  paresis  and  tabes  as  two  distinct  affections 
which  are  sometimes,  though  rarely,  associated  in  the 
same  subject.3 

(b)  Combined  sclerosis. — The  degeneration  involves 
both  the  posterior  and  the  lateral  columns.  Moreover, 
the    process    here   is  more   diffuse   and  affects  simul- 

1  Nageotte.      Tabes  et  Paralysie  generate.     These  de  Paris,  1893. 

2  Rabaud.  Contribution  a  V etude  des  lesions  spinales  posterieures 
dans  la  paralysie  generate.     These  de  Paris,  1898,  p.  105 

3  Joffroy.  De  la  paralysie  generate  a  forme  tabetique.  Nouvelle 
iconographie  de  la  SalpStriere,  1895. 


GENERAL   PARESIS.  239 

taneously  different  systems  of  fibers  (tract  of  Gowers, 
crossed  pyramidal  tract). 

(C)  Peripheral  nerves. — The  lesions  of  the  peripheral 
nerves  consist  in  the  phenomena  of  peripheral  neuritis 
and  atrophy,  analogous  to  those  encountered  in  tabes 
and  in  alcoholism. 

(D)  Viscera. — Three  classes  of  lesions  may  be  dis- 
tinguished in  the  viscera: 

(1)  Lesions  occurring  merely  as  accidental  compli- 
cations: various  infections,  broncho-pneumonia,  tuber- 
culosis. The  latter  is  rare  and  usually  runs  a  slow 
course. 

(2)  Lesions  which  are  the  direct  consequences  of  the 
nervous  disorders.  These  have  been  studied  exhaus- 
tively by  Klippel,  who  has  termed  them  vaso-para- 
lytic  lesions.  They  consist,  according  to  this  author, 
"in  a  high  degree  of  congestion  and  capillary  engorge- 
ment, capillary  hemorrhages,  and,  by  consequence, 
atrophic  degeneration  of  epithelial  tissues."  * 

(3)  Diffuse  vascular  lesions  identical  in  appearance 
and  probably  also  in  their  nature  and  origin  with  those 
of  the  cerebral  vessels.  Angiolella  attributes  them 
to  the  action  of  a  toxic  substance.  We  shall  see  their 
pathological  importance  later  on. 

These  lesions  are  met  with  chiefly  in  the  kidneys,  liver, 
and  heart,  and  are  often  associated  with  degenerative 


1  Klippel.  Lesions  des  poumons,  du  cceur,  du  foie  et  des  reins 
dans  la  paralysie  generate.  Arch,  de  med.  experim.  et  d'anat. 
path.,  July  1892. — Angiolella.  Lesions  des  petits  vaisseaux  de 
quelques  organes  dans  la  paralysie  generate.  II  manieomio,  1895, 
Nos.  2  and  3. 


240  MANUAL  OF  PSYCHIATRY. 

lesions,  such  as  fatty  or  cirrhotic  liver,  sclerotic  kidney, 
or  degenerated  myocardium. 

Etiology. — The  etiology  of  general  paresis  is  one  of 
the  most  arduous  subjects  in  psychiatry.  The  labors  of 
recent  years  have  contributed  much  towards  its  solu- 
tion. It  cannot  be  said,  however,  that  this  question 
is  at  the  present  time  definitely  settled. 

(A)  Predisposing  causes. — Sex. — Men  are  much  more 
exposed  than  women  1  to  general  paresis,  although  the 
difference  is  not  so  great  as  was  generally  believed  some 
years  ago;  this  difference  varies  in  different  communi- 
ties. Exceptional  in  women  in  the  country,  general 
paresis  occurs  in  the  proportion  of  one  case  in  women  to 
four  in  men  in  the  large  cities  (Paris,  Berlin,  Hamburg) . 

The  menopause  and  the  puerperal  state  seem  to  favor 
its  appearance. 

It  often  presents  a  peculiar  aspect  in  women.  The 
demented  and  the  depressed  forms  predominate.  Delu- 
sions when  present  are  usually  childish.  The  patient 
is  proud  of  her  looks,  of  her  dress,  etc. 

Age. — Rare  before  thirty  years,  general  paresis  is, 
however,  met  with  in  youth  and  even  in  childhood,  con- 
stituting the  juvenile  and  infantile  forms. 

Etiologically  these  cases  usually  present  a  neurotic, 
alcoholic,  and  syphilitic  heredit}^.  Clinically  juvenile 
or  infantile  general  paresis  is  characterized  by  an 
accentuation  of  the  physical  signs  and  by  absence  of 
delusions.2 


1  Cr6te.     Quelques    observations   sur    la    paralysie   generate   de   la 
femme  et  la  paralysie  generate  conjugate.     These  de  Paris,  1899. 

2  Toulouse.     La  paralysie  generate  juvenile.     Gazette  des  hopitaux 


GENERAL  PARESIS.  241 

General  paresis  scarcely  ever  begins  after  the  age  of 
fifty-five  years.  Possibly,  however,  some  cases,  rather 
carelessly  classified  as  senile  dementia,  are  in  reality 
cases  of  general  paresis  of  late  onset. 

Social  factors. — General  paresis  is  not,  as  was  once 
believed,  the  sad  privilege  of  cultured  men.  It  affects 
the  working  classes  as  well  as  the  upper  classes. 

It  is  much  more  common  in  urban  than  in  rural  com- 
munities, probably  because  syphilis,  alcoholism,  and 
stress,  the  influence  of  which  will  be  studied  later,  are 
more  frequent  in  the  cities. 

Individual  predisposition. — Entertained  formerly  by 
Mattern,  Mackenzie,  and  Bakon,  and  in  our  own  times 
by  Scholtens,  the  opinion  that  general  paresis  is  an 
accidental  affection  which  may  occur  in  an  individual 
free  from  all  predisposition  has  to-day  scarcely  any 
adherents. 

The  predisposition  is  most  frequently  heredita^. 
Some  are  of  the  opinion  that  the  hereditary  factor  is 
usually  an  organic  disease  in  the  ascendants:  apoplexy, 
tabes,  etc.  Ball  and  Regis  have  studied  the  genealogy 
of  one  hundred  general  paretics  and  found  in  their 
family  but  four  insane  individuals,  while  the  number 
of  those  afflicted  with  organic  nervous  diseases  mounted 
to  one  hundred  and  forty  three. 


1898. — Regis.  Arch.  din.  de  Bordeaux,  July  and  August  1892. — 
Joffroy.  Revue  de  Psychiatrie,  1898. — Thiry.  Paralysie  ginlrale 
juvenile.  These  de  Nancy,  1898. — Durpas  et  Marchand.  Ann. 
med.  psych.,  1901. — Mott.  Notes  of  Twenty-two  Cases  of  Juvenile 
General  Paralysis,  Arch,  of  Neurology,  1899. — Legrain.  Contribu- 
tion a  V etude  de  la  paralysie  generate  chez  V adolescent.  Ann.  de  la 
policlin.  de  Paris,  1893. 


242  MANUAL  OF  PSYCHIATRY. 

Another  opinion,  which  I  believe  has  a  wider  accept- 
ance, is  that  general  paresis  may  occur  in  individuals 
coming  from  neuropathic  families  in  the  members  of 
which  may  be  encountered  organic  nervous  affections 
as  well  as  functional  neuroses  and  psychoses.  This 
view  is  held  by  Joffroy  in  France,  Funaioli  in  Italy, 
and  Nacke  in  Germany,  who  have  arrived  at  the  same 
conclusion  by  different  methods. 

Acquired  predisposition  is  usually  the  result  of  over- 
work, chronic  intoxications,  etc.  Cases  in  which  no 
hereditary  influence  can  be  found  belong  to  this  cate- 
gory.1 

The  predisposition  is  often  latent,  so  that  the  future 
general  paretic  may  appear  as  a  perfectly  normal 
individual.  Sometimes,  however,  meningo-encephalitis 
attacks  true  degenerates  (Joffroy)  and  even  imbeciles 
(Cullerre).2 

(B)  Determining  causes. — The  most  important  are 
violent  or  prolonged  emotions,  overwork,  cranial  trau- 
matisms, alcoholism,  and  syphilis.  These  are  not, 
however,  of  equal  importance.  Alcoholism  and  syphilis 
are  in  this  respect  far  ahead  of  the  rest. 

Emotions. — In  the  histories  of  general  paretics  we 
often  find  grief,  financial  losses,  and  sudden  fright  as 
causes.  A  servant-woman,  forty  years  of  age,  having 
had  her  clothing  torn  by  a  shell  during  the  siege  of 

1  Joffroy.  Congres  des  medecins  alienist es  et  neurologistes, 
Angers,  1898. — Funaioli,  quoted  by  Mariani.  L' her  Mite  chez  les 
paralytiques  generaux.  These  de  Paris,  1899. — Nacke.  Die 
sogenannten  ciusseren  Degenerationszeichen  hex  progressive  Paralyse. 
Allg.  Zeits.  f.  Psych.,  1899. — Wahl.  Etude  sur  la  descendance  des 
paralytiques  generaux.     These  de  Paris,  1898. 

2  Joffroy.     hoc.  cit. — Cullerre.    Paralysie  generale  chez  un  imbecile. 


GENERAL  PARESIS.  243 

Strasbourg,  soon  after  showed  signs  of  mental  derange- 
ment, and  five  years  later  was  admitted  to  the  hospital 
with  unmistakable  signs  of  general  paresis.1 

Overwork. — Either  physical  or  intellectual  overwork 
is  quite  a  frequent  cause.  In  many  observations  depri- 
vation of  sleep  has  been  found. 

All  kinds  of  excesses,  especially  venereal  excesses, 
when  they  are  not  due  to  the  disease  itself,  act  through 
the  general  impairment  of  health  which  they  bring 
about. 

Cranial  traumatisms. — Their  influence  as  etiological 
factors,  though  denied  by  some  authors,  Hirschl  among 
them,  is  however  admitted  by  most  observers.  Some- 
times the  phenomena  of  paresis  appear  soon  after  the 
injury;  in  most  cases,  however,  they  appear  after  an 
interval  of  varying  duration.  Traumatisms  should, 
therefore,  be  considered  chiefly  as  predisposing  causes.2 

Alcoholism. — Already  Bayle  has  pointed  out  the 
importance  of  alcohol  in  the  causation  of  general  paresis. 
Calmeil  and  Marce  also  recognized  it.  Among  the  mod- 
ern authors  who  consider  alcoholism  as  a  prominent 
etiological  factor  in  general  paresis  may  be  mentioned 
Joffroy,  Magnan,  Dagonet,  Gamier,  Mendel.3  "  General 
paresis  occurs  quite  frequently  as  a  result  of  the 
abuse  of  alcohol  in  predisposed  individuals  "  (Joffroy). 

1  Mendel.     Loc.  cit. ,  p.  255. 

2  Vallon.  De  la  paralysie  generate  et  du  traumatisme.  These 
de  Paris,  1879. — Meschede.  Paralytische  Geistesstorungen  nach 
Trauma.    .Allg.   Zeitsch.   fur  Psychiat.,   1899. 

3  Joffroy.  Gaz.  des  hopitaux,  1895. — Mendel.  Loc  cit. — Gar- 
nier.  Progres  medic,  1889. — Hoppe.  Allg.  Zeitsch.  f.  Psychiat. 
I,  58,  No.  6. — Funaioli.  Suite  cause  e  sulla  profilassi  delta  pazzia, 
1900. 


244  MANUAL  OF  PSYCHIATRY. 

"The  abuse  of  alcohol  is  undoubtedly  a  frequent  cause 
of  general  paresis"  (Mendel). 

Some  authors,  however,  do  not  look  upon  alcoholism 
as  any  more  than  a  predisposing  cause.  But  whatever 
be  its  mode  of  action  it  constitutes  a  causative  agent 
of  primary  importance.  Numerous  statistics  sub- 
stantiate this;  as  being  among  the  most  recent  and  the 
most  conclusive  may  be  mentioned  those  of  Hoppe 
and  of  Funaioli. 

Syphilis. — We  have  now  come  to  the  most  important 
and  possibly  the  essential  cause,  sine  qua  non,  of  diffuse 
meningo-encephalitis . 

In  1857  Esmarch  and  Jessen  came  to  the  conclusion 
that  syphilis  is  the  cause  of  general  paresis.  Disputed 
at  first,  this  idea  soon  found  acceptance  in  many  coun- 
tries, especially  in  Germany.  In  France  it  gained 
ground  more  slowly.  Charcot  always  rejected  it. 
Dejerine  wrote  in  1886:  "Syphilis  is  very  rarely  found 
in  the  histories  of  general  paretics,  and  has  no  influence 
upon  the  course  of  the  affection.  Its  occurrence  in 
paretics  is  but  a  coincidence" 

However,  statistics  of  various  authors  have  furnished 
uch  unmistakable  and  uniform  figures  that,  with  a 
few  rare  exceptions,  all  authors  to-day  consider  syphilis 
as  a  factor  of  high  importance  in  the  causation  of 
general  paresis.1 

1  Regis.  Syphilis  et  paralysie  generate.  Arch.  clin.  de  Bordeaux, 
July  and  August  1892. — Fournier.  Des  affections  parasyphilitiques, 
Paris,  1894. — Ballet.  Loc.  cit. — Sprengeler.  Beitrag  zur  Statistic, 
etc. ,  der  allgemeinen  progressiven  Paralyse.  Allg.  Zeitsch.  f .  Psychiat. 
— Fournier.  Rapport  de  la  syphilis  et  de  la  paralysie  generate 
Arch.  gen.  de  Med.,  Dec.  1894. 


GENERAL  PARESIS.  245 

But  is  syphilis  the  essential  and  specific  cause  of  the 
affection?     On  this  point  the  opinions  are  divergent. 

Some  claim,  like  Fournier,  that  general  paresis  is  a 
disease  of  syphilitic  origin,  a  parasyphilitic  affection; 
others  believe  with  Joffroy  that  syphilis  is  but  an 
adjuvant — a  powerful  one,  it  is  true — which  favors  the 
occurrence  of  the  disease  but  does  not  alone  suffice 
to  produce  it. 

The  limits  of  this  work  do  not  permit  of  a  detailed 
exposition  of  the  arguments  advanced  in  favor  of  each 
opinion.  Moreover  there  is  no  conclusive  proof  of 
either  theory.  Statistics  can  give  us  only  strong 
probabilities,  not  certainties. 

The  uselessness  of  specific  treatment  in  most  of  the 
cases  of  general  paresis  does  not  prove  that  the  disease 
is  not  of  syphilitic  origin:  are  there  not  lesions,  espe- 
cially of  the  cord,  the  syphilitic  origin  of  which  is  doubted 
by  no  one,  but  which  are  not  in  the  least  influenced 
by  the  most  thorough  specific  treatment? 

For  a  long  time  the  adversaries  of  the  syphilitic 
origin  of  the  disease  have  offered  the  so-called  anato- 
mico-pathological proof.  They  argued  that  syphilis 
occasions  circumscribed  lesions,  while  the  lesions  of 
general  paresis  are  diffuse.  Ballet  has  shown  the  un- 
soundness of  this  argument: 

(1)  It  constitutes  a  mere  petitio  principii,  for  there 
is  nothing  to  prove  that  we  already  know  all  the 
lesions  of  syphilis. 

(2)  There  are  diffuse  syphilitic  myelites,  and  con- 
sequently there  is  nothing  against  the  existence  of  a 
diffuse  meningo-encephalitis ;  that  is  too  say,  syphilitic 
general  paresis. 


246  MANUAL  OF  PSYCHIATRY. 

(3)  The  vascular  lesions  of  general  paresis  are  iden- 
tical with  those  encountered  in  certain  syphilitic  affec- 
tions of  the  viscera  (liver,  kidneys),  and  even  in  syphilitic 
cerebral  lesions  (Mahaim). 

Thus  the  anatomico-pathological  proof  falls  of  itself. 
But  could  the  partisans  of  the  syphilitic  origin  look 
upon  this  as  an  argument  in  proof  of  their  theory? 
It  seems  to  me  that  this  would  be  a  petitio  principii  on 
their  part,  for,  if  we  cannot  assume  that  we  are  ac- 
quainted with  all  the  lesions  that  syphilis  can  produce, 
we  are  equally  unable  to  assume  that  syphilis  is  the 
only  factor  capable  of  producing  these  lesions  of  the 
blood-vessels  and  other  tissues. 

Does  the  comparative  pathology  of  races  clear  up 
this  point?  It  is  certain  that  syphilis  is  frequent  and 
that  general  paresis  is  rare  among  the  Arabs,  Abyssin- 
ians,  and  South  Africans,  as  was  shown  by  Ballet; 
but  this  proves  nothing  at  all.  It  is  quite  possible 
that  syphilis  cannot  produce  the  lesions  of  chronic 
meningo- encephalitis  except  under  certain  conditions 
created  by  civilization  and  absent  among  primitive 
and  low  races.  The  partisans  of  the  syphilitic  origin 
do  not  deny  the  necessity  of  a  predisposition. 

Krafft-Ebing  presented  at  the  International  Congress 
of  Medicine  at  Moscow  results  of  experiments  con- 
stituting an  incontrovertible  argument  in  favor  of 
the  syphilitic  origin,  even  though  the  experiments 
were  made  upon  a  limited  number  of  subjects.  A 
physician,  whose  name  is  not  mentioned,  inoculated 
with  syphilis  nine  general  paretics  who  had  reached 
the  last  stage  of  the  disease  and  in  whose  history  syphilis 
was  not  to  be  found:   not  one  of  these  developed  the 


GENERAL   PARESIS  247 

indurated  chancre.  This  experiment  repeated  upon 
a  large  number  of  patients  can  afford  a  solution  to 
this  great  problem.  For  obvious  moral  reasons  prob- 
ably very  few  will  ever  be  tempted  to  undertake  this 
work. 

Thus  at  the  present  time  we  have  no  conclusive 
evidence  either  for  or  against  the  syphilitic  origin  of 
general  paresis.  In  the  absence  of  positive  proof  the 
following  conclusions,  though  provisional,  seem  to  be 
most  nearly  in  accord  with  the  facts:  (1)  the  frequency 
of  syphilis  in  the  histories  of  general  paretics  is  unques- 
tionable; (2)  undoubtedly  syphilis  is  a  highly  impor- 
tant factor  in  the  etiology  of  the  disease;  (3)  in  the 
present  state  of  our  knowledge  of  the  subject  it  is 
impossible  to  affirm  that  general  paresis  is  a  syphilitic 
disease. 

The  ultimate  nature  of  the  disease  is  still  unknown. 
Perhaps  it  constitutes  merely  a  syndrome  which  can 
be  produced  by  diverse  causes,  and  it  would  perhaps 
be  more  correct  to  speak  of  general  pareses  than  of  one 
general  paresis. 

One  fact  seems  to  be  certain :  the  morbid  agent,  what- 
ever it  may  be,  exerts  its  action  not  solely  upon  the 
nervous  system,  but  upon  the  entire  organism.  This  is 
proved  by  the  constant  presence  of  lesions  and  func- 
tional disturbances  of  the  viscera. 

The  diffuse  character  of  the  lesions  together  with 
certain  clinical  features  of  the  disease,  notably  the 
frequency  of  epileptiform  attacks,  have  led  Kraepelin 
to  formulate  an  ingenious  hypothesis,  only  the  principle 
of  which  I  shall  mention  here,  but  a  detailed  exposition 
of  which  is  to  be  found  in  the  magnificent  work  of  that 


248  MANUAL  OF  PSYCHIATRY. 

author.1  According  to  him,  general  paresis  is  a  disease 
of  autointoxication.  The  poison  results  from  a  dis- 
ordered metabolism  the  cause  of  which  is  often,  but 
not  always,  syphilis.  When  this  disorder  is  once 
established  the  evolution  of  the  disease  takes  place 
automatically,  so  that  the  late  accidents  have  nothing 
to  do  with  the  original  cause.  When  the  thyroid  body 
is  destroyed,  whether  it  be  by  syphilis,  by  tuberculosis, 
or  by  a  tumor,  the  consequence  is  invariably  myxce- 
dema;  why,  then,  should  an  alteration  of  some  essen- 
tial function,  either  by  syphilis,  alcoholism,  or  any 
other  morbid  agent,  not  be  manifested  ultimately  by 
the  same  phenomena,  that  is  to  say  by  the  symptoms 
and  lesions  of  general  paresis? 

Treatment. — This  is  but  symptomatic.  As  is  ad- 
mitted even  by  partisans  of  the  syphilitic  origin,  specific 
treatment  exercises  absolutely  no  favorable  influence 
upon  the  course  of  the  disease.  If  the  hypothesis  of 
Kraepelin  is  correct,  this  fact  is  not  surprising;  when 
the  first  symptoms  of  general  paresis  appear,  syphilis 
has  already  accomplished  its  work,  and  it  is  too  late 
for  combating  it. 

Rest  and  avoidance  of  all  excitement  and  fatigue  are 
the  only  means  at  our  disposal  for  retarding  to  some 
extent  the  course  of  the  disease. 

Excitement,  insomnia,  refusal  of  food,  involuntary 
evacuation  of  urine  and  faeces,  and  the  other  symptoms 
are  to  be  treated  by  the  usual  methods. 

By  special  care  with  regard  to  the  cleanliness  of  the 
patient,  by  allowing  him  to  remain  out  of  bed  for 

1  Lehrbuch  der  Psychiatrie,  Vol.  II,  p.  381. 


GENERAL  PARESIS.  249 

several  hours  each  day,  or  by  frequently  changing  his 
position  in  bed,  by  the  use  of  air-  or  water-beds,  and 
by  promptly  attending  to  beginning  ulcerations,  using 
an  antiseptic  and  tonic  lotion,  it  is  quite  possible  to 
avoid  bed-sores,  to  heal  them,  or  at  least  to  retard  the 
progressive  ulceration. 

Enemata,  leeches  to  the  mastoid  processes,  sinapisms 
to  the  lower  extremities,  and  topical  blood-letting 
constitute  the  classical  and  perhaps  efficacious  treat- 
ment for  the  seizures.  Continued  convulsions  are 
sometimes  successfully  combated  by  rectal  injections 
of  chloral  or  by  inhalations  of  chloroform. 


CHAPTER  X. 

MENTAL  DISORDERS   DUE   TO   ORGANIC   CEREBRAL 

AFFECTIONS. 

All  the  so-called  organic  cerebral  affections,  whether 
diffused  or  localized,  have  an  influence  upon  the  psychic 
functions. 

Among  the  most  important  may  be  mentioned  general 
arteriosclerosis  (arteriosclerotic  degeneration  of  Alz- 
heimer), chronic  subcortical  encephalitis  of  Binswanger, 
cerebral  tumors,  abscess  of  the  brain,  chronic  meningeal 
inflammatory  lesions,  hemorrhages,  and  softening  of  the 
brain. 

As  met  with  in  a  slighter  degree  of  intensity  the 
psychic  manifestations  of  these  different  pathological 
conditions  are  limited  to  a  certain  sluggishness  of  idea- 
tion and  change  of  character. 

In  the  more  marked  cases  this  sluggishness  of  ideation 
becomes  intellectual  obtuseness.  The  patient  understands 
none  but  the  simplest  questions;  he  is  incapable,  even 
independently  of  any  aphasia,  of  sustaining  a  con- 
tinued conversation.  He  is  sometimes  disoriented, 
does  not  know  exactly  where  he  is,  and  loses  the  notion 
of  time. 

AH    psychic    activity  is  half   extinguished.     Weeks 

250 


ORGANIC  CEREBRAL  AFFECTIONS.  251 

r 

and  months  pass  in  a  sort  of  a  dreamy  state,  during 
which  the  patient  neglects  his  daily  duties.  He  requires 
constant  care  like  a  child  and  must  be  fed,  dressed, 
washed,  and  combed.  In  grave  cases  the  patient  con- 
stantly wets  and  soils  himself,  and  this  filthiness  can 
be  prevented  only  by  the  most  careful  supervision. 

The  memory  is  profoundly  affected.  Current  events 
make  no  impression  upon  the  mind.  Old  impressions 
become  effaced,  following  the  law  of  retrogression. 

The  moral  indifference,  always  very  marked,  is  apt 
to  be  interrupted  by  outbursts  of  anger  or  emotionalism 
which  appear  without  provocation  and  closely  resem- 
ble those  met  with  in  senile  dementia. 

Diverse  accidental  symptoms,  which  are  often  due  to 
a  localization  of  the  morbid  process,  may  complicate 
the  above-described  psychic  disorders.  Such  are  hallu- 
cinations and  delusions  which  assume  the  most  varied 
forms. 

The  psychic  disorders  in  themselves  exhibit  nothing 
pathognomonic,  and  the  diagnosis  must  be  based  upon 
the  physical  symptoms:  paralyses,  anaesthesias,  dis- 
orders of  speech,  etc. 

Cerebral  tumors  may  readily  simulate  general  paresis. 
Weber  has  reported  a  curious  observation  upon  a  case 
of  multiple  cerebral  tubercles  which  gave  rise  to  symp- 
toms typical  of  general  paresis.  In  doubtful  cases 
particular  attention  should  be  paid  to  localization 
symptoms,  and  especially  to  the  state  of  the  optic  disc. 
Choked  disc,  almost  constant  in  cerebral  tumors,  is 
never  seen  in  general  paresis. 

The  mental  disorders  in  such  cases  present  certain 
peculiarities   which  may  aid  in  the  diagnosis.     Dupre 


252  MANUAL  OF  PSYCHIATRY. 

and  Devaux  x  have  found  that  "  patients  suffering  from 
cerebral  tumor  present  a  peculiar  state  of  mental 
depression  and  enfeeblement,  which  constitutes  their 
dominant  psychopathic  note :  this  state  is  one  of  torpor, 
psychic  dullness,  and  clouding  of  the  intellect,  to  which 
may  be  added  mental  puerilism."  Properly  speaking 
these  cases  present  no  true  dementia  until  the  affection 
has  reached  its  terminal  period.  According  to  the 
same  authors2  "the  intelligence,  though  clouded,  is 
not,  however,  destroyed.  It  responds  to  strong  stimuli, 
to  imperious  injunctions;  it  is  veiled,  but  nevertheless 
present,  and  it  is  not  until  the  last  phases  of  the  develop- 
ment of  the  affection  that  it  declines  and  finally  dis- 
appears." 

It  is  a  generally  accepted  opinion,  the  correctness  of 
which  is  often  verified  clinically,  that  psychic  disorders 
occur  chiefly  as  manifestations  of  frontal  tumors. 

Syphilitic  disease  of  the  brain  is  often  difficult  to 
distinguish  from  general  paresis.  Besides  the  localiza- 
tion symptoms  which  it  most  frequently  gives  rise  to, 
special  attention  is  to  be  paid  to  the  character  of  the 
intellectual  enfeeblement.  Binswanger  has  given  a  very 
good  description  of  it:3  "  Post-syphilitic  dementia  has 
a  peculiar  evolution:  it  develops  in  acute  or  subacute 
attacks  which  occur  as  a  result  of  gummatous  affections 
of  the  meninges,  of  the  brain,  or  of  the  vessels;  the 
dementia    remains    stationary  #  unless    new    syphilitic 

1  Nouvelle  iconographie  de  la  Salpetriere.  Tumeur  cerebrate.  1901, 
Nos.  2  and  3,  p.  51. 

2  hoc.  cit.,  p.  8. 

3  Beitrdge  zvr  Pathogenese,  etc.  Festschrift  gewidmet  Prof.  Dr. 
Emil  Ponfick.     Breslau,  1900. 


ORGANIC  CEREBRAL  AFFECTIONS.  253 

lesions  occur  to  cause  its  further  progress.  Moreover, 
specific  treatment,  if  instituted  at  the  time  of  the  ap- 
pearance of  the  lesions,  has  an  influence  upon  cerebral 
syphilis.  This  special  evolution  distinguishes  syphilitic 
dementia  from  general  paresis,  which  usually  establishes 
itself  insidiously  and  the  course  of  which  is  progressive." 

When  localization  symptoms  occur  in  general  paresis 
they  are  but  transitory,  save  in  exceptional  cases.  This 
feature  distinguishes  them  from  the  permanent  paralyses 
of  softening  and  of  hemorrhage  of  the  brain.  The  peculiar 
impairment  of  speech  of  the  general  paretic  is  distin- 
guished by  its  ataxic,  hesitating  character  from  the 
indistinct  speech  of  the  hemiplegic. 

Senile  dementia  never  presents  localization  symptoms, 
except  in  the  cases  where  actual  hemorrhage  or  soften- 
ing occurs  in  addition  to  the  cerebral  atrophy.  It  is 
then  almost  impossible  to  distinguish  the  part  played 
by  the  senile  process  from  that  of  the  localized  lesion. 
Such  is  also  the  case  with  alcoholic  dementia,  which, 
like  senile  dementia,  is  quite  likely  to  be  complicated  by 
the  lesions  of  softening  or  of  hemorrhage.  The  two 
morbid  processes  are  so  intimately  correlated  that  it  is 
impossible  to  distinguish  their  manifestations. 

The  intellectual  enfeeblement  of  dementia  prcecox 
differs  greatly  from  that  of  organic  dementia.  General- 
ized in  the  latter,  the  dementia  in  the  former  is,  on  the 
contrary,  elective.  The  physical  symptoms  which  may 
somewhat  resemble  localization  symptoms  are  usually 
slight  and  transitory.  The  question  is  more  complicated 
where  an  organic  lesion  is  associated  with  dementia 
prsecox,  which  sometimes  happens.  I  have  seen  a  pre- 
cocious dement  who  presented  a  hemiplegia  of  syphilitic 


254  MANUAL  OF  PSYCHIATRY. 

origin.  The  character  of  the  dementia  is  then  greatly 
modified.  The  impairment  of  the  memory  in  such 
cases  runs  a  rapid  course  not  seen  in  ordinary  cases  of 
dementia  praecox. 

The  pathogenesis  of  mental  disorders  dependent  upon 
the  so-called  organic  cerebral  lesions  is  rather  complex. 
While  it  is  quite  intelligible  how  diffuse  lesions  (general- 
ized arteriosclerosis,  diffuse  cerebral  syphilis)  can  bring 
about  psychic  symptoms,  it  is  not  so  clear  how  a  local- 
ized lesion,  such  as  abscess,  cerebral  tumor,  localized 
meningitis,  can  disturb  the  intelligence, — a  function 
that  is  not  definitely  localized. 

For  a  long  time  the  psychical  symptoms  have  been 
attributed  to  the  increased  tension  of  the  cerebrospinal 
fluid  which  produces  cerebral  compression.  This  opinion 
is  quite  tenable.  It  cannot,  however,  be  adopted  exclu- 
sively. Dupre  and  Devaux  have  in  fact  recently  shown 
that  a  role  of  primary  importance  is  played  by  a  toxi- 
infectious  process  the  starting-point  of  which  is  the 
local  lesion:  "  In  the  pathogenesis  of  cerebral  tumors, 
aside  from  the  cerebral  compression,  which  is  perhaps  of 
considerable  importance  in  itself,  it  is  necessary  to 
assign  a  place  to  the  action  upon  the  nervous  elements 
of  toxic  products  which  are  secreted  by  the  neoplasm.  In 
favor  of  this  hypothesis  there  are  certain  arguments: 
the  hysto-pathological  (changes  in  the  cortical  cells  and 
optic  nerves  similar  to  toxi-infectious  lesions),  the 
anatomical  (free  communication  between  the  blood- 
and  lymph-vessels  of  the  neoplasm  and  those  of  the 
brain,  which  permits  of  the  impregnation  of  the  cerebral 
tissues  by  toxines  from  the  pathological  focus;  extreme 
sensitiveness  of  the  gray  matter  to  toxines),  and  the 


ORGANIC  CEREBRAL  AFFECTIONS.  255 

clinical  (the  analogy  existing  between  the  clinical  picture 
of  toxic  encephalopathies, — uraemia,  diabetes,  plumb- 
ism,  etc., — and  that  of  neoplasmic  encephalopathy). 
Cerebral  intoxication  ought,  therefore,  to  be  assigned 
a  place  among  the  pathogenic  factors  (compression, 
irritation,  vascular  phenomena),  which  are  accepted  as 
accounting  for  the  symptomatology  of  cerebral  tumors."1 

x  hoc.  tit.,  p.  51. 


CHAPTER  XI. 
PSYCHOSES  OF  INVOLUTION. 

§  1.  Affective  Melancholia.1 

The  causes  of  this  disease  are  not  well  known. 
Hereditary  or  congenital  predisposition  is  found  in 
about  60%  of  the  cases.  The  most  frequent  factors 
are  grief,  stress,  infectious  diseases, — tuberculosis  in 
particular, — and  in  women  the  menopause.  Occurring 
chiefly  after  forty-five  years  of  age,  it  seems  to  be 
intimately  connected  with  the  phenomena  of  organic 
retrogression  beginning  at  this  age;  hence  the  name 
"involution  melancholia,  "  which  is  often  applied  to  this 

disease. 

The  prodromal  period,  which  is  almost  constant 
and  usually  very  long,  indicates  a  profound,  slow,  and 
progressive  change  of  the  entire  organism:  the  process 
of  digestion  is  painful;  there  is  anorexia,  insomnia, 
irritability,  unwarranted  pessimism,  and  a  tendency  to 
rapid  fatigue. 

Finally  the  disease  sets  in,  characterized  from  the 
beginning  by  the  intensity  of  the  moral  pain,  which 


1  [The  term  affective  melancholia  has  been  used  by  Wernicke  to 
designate  a  condition  corresponding  to  the  depressed  type  of  manic 
depressive  insanity.  The  reader  will  observe  that  it  is  used  here  in 
an  entirely  different  sense.] 

256 


PSYCHOSES  OF  INVOLUTION  257 

renders  the  malady  deserving  of  the  name  affective 
melancholia. 

It  presents  itself  with  the  train  of  physical  and 
psychical  symptoms  already  studied  in  connection  with 
active  depression.  When  associated  with  anxiety,  it 
gives  rise  to  anxious  melancholia.1 

The  anxiety  may  result  either  in  agitation  (melancholia 
agitata)  or  in  stupor.  In  the  latter  case  the  patient 
appearsas  though  dumfounded  with  the  pain.  "A 
frightful  internal  anxiety  constitutes  the  fundamental 
state   which   torments   him   almost    to    suffocation." 2 

When  the  moral  pain  is  very  marked,  it  entails  some- 
times a  certain  degree  of  mental  confusion  which  is  most 
frequently  transitory  and  subject  to  the  same  fluctua- 
tions as  the  moral  pain,  of  which  it  is  a  manifestation. 

In  cases  of  slight  or  moderate  intensity  the  lucidity 
is  perfect  and  sometimes  permits  the  patient  to  analyze 
his  case  with  considerable  minuteness. 

The  associations  of  ideas  are  sluggish,  less  so,  how- 
ever, than  in  the  depressed  form  of  manic  depressive 
insanity.  We  have  seen,  in  fact,  that  the  intensity 
of  psychic  inhibition  is  inversely  proportional  to  that 
of  the  moral  pain;  naturally,  therefore,  the  inhibition 
occupies  here  a  secondary  position.  Between  the 
cases  in  which  the  moral  pain  clearly  predominates  and 
those  in  which  the  inhibition  is  the  principal  feature, 
there  is  a  host  of  intermediary  forms  which  establish 
an  insensible  transition  between  affective  melancholia 
and  manic  depressive  insanity.     These  two  affections 

1  Capgras.  Essai  de  reduction  de  la  mclancolie  a  une  psy chose 
d'involution  presenile.  These  de  Paris,  1900. — Kraepelin.  Lehr- 
buch  der  Psychiatrie. 

2  Griesinger.    hoc.  cit.f  p.  292, 


258  MANUAL  OF  PSYCHIATRY. 

seem  to  be  closely  related  to  each  other,  and  borderland 
cases  are  not  infrequent. 

Moreover,  the  moral  pain  may  in  itself  become  a 
cause  of  psychic  inhibition  and  create  affective  melan- 
cholia with  stupor. 

To  these  psychic  phenomena  are  added  physical  dis- 
orders most  of  which    have  already  been  considered: 

Respiratory  and  circulatory  disturbances  which  de- 
pend upon  the  depression  and  anxiety; 

Disturbance  of  the  digestive  .f mictions:  anorexia, 
dyspepsia,  painful  digestion,  constipation; 

Impairment  of  the  general  nutrition,  changes  in  the 
composition  of  the  urine  (diminution  of  urea,  slight 
albuminuria),  and  rapid  loss  of  flesh.  This  latter 
symptom  is  of  particular  importance;  a  rise  in  weight 
always  indicates  the  termination  of  the  acute  period: 
the  patient  is  either  entering  upon  his  convalescence 
or  lapsing  into  dementia; 

The  menses  are  usually  suppressed.  Their  reap- 
pearance has  the  same  prognostic  significance  as  the 
return  of  the  normal  weight:  it  indicates  either  the 
approach  of  recovery  or  the  passage  into  a  chronic  state ; 

Finally,  there  are  various  nervous  troubles:  headache, 
palpitation,  tremors,  hysteriform  crises,  and  insomnia. 

These  are  the  fundamental  symptoms  of  affective 
melancholia  in  its  simplest  form  and  uncomplicated 
by  delusions.  This  form  is  rare,  for  almost  always 
delusions  are  present  in  addition  to  the  above  symptoms 
(delusional  affective  melancholia). 

All  varieties  of  melancholy  delusions  are  encountered 
in  this  affection:  ideas  of  culpability,  of  humility,  of 
ruin,    hypochondriacal   ideas,    and   ideas   of   negation. 


PSYCHOSES  OF  INVOLUTION.  259 

The  syndrome  of  Cotard  scarcely  ever  appears  except 
in  the  chronic  forms. 

With  the  appearance  of  intellectual  enfeeblement  the 
delusions  become  absurd  and  incoherent,  as  they  are 
in  all  states  of  dementia. 

Hallucinations  are  not  frequent.  The  least  rare  are, 
according  to  Seglas,  those  of  vision.  Those  of  hearing, 
taste,  and  smell  are  occasionally  met  with,  while  those 
of  general  sensibility  are  altogether  exceptional. 

Illusions  of  all  sorts  are,  on  the  contrary,  frequent.  They 
are  quite  likely  to  assume  the  form  of  false  recognitions. 

Finally,  delusional  interpretations  are  constant.  The 
patient  hears  the  noise  of  hammer-etrokes  in  his  vicinity 
and  thinks  they  are  preparing  a  scaffold  for  him.  He 
hears  the  sound  of  voices  in  the  street  and  thinks  the 
mob  is  going  to  seize  and  lynch  him,  etc. 

The  reactions  are  usually  in  harmony  with  the 
melancholy  state  and  with  the  nature  of  the  delusions. 
Sometimes  they  assume  an  exclusively  automatic 
character;  it  is  to  be  noted  that  negativism  is  not  at 
all  rare.  The  agitation  may  be  extremely  violent  and 
sudden,  and  it  may  be  accompanied  by  profound 
clouding  of  consciousness  (raptus  melancholicus) . 

Melancholia  may  terminate  in: 

(a)  Complete  recovery  [32%]; 

(b)  An  improvement  sufficient  to  allow  the  patients 
to  return  to  normal  life  [23%]; 

(c)  A  lapse  into  a  chronic  state  marked  by  a  diminu- 
tion of  the  emotional  depression  and  by  the  appear- 
ance of  intellectual  enfeeblement.  The  latter  consists 
chiefly  in  a  certain  degree  of  incoherence  analogous 
to  that  noted  in  dementia  precox  [26%]; 


260  MANUAL  OF  PSYCHIATRY. 

(d)  Death  [19%], *  which  may  be  due  to: 

(I)  Suicide,  which  is  the  more  likely  to  occur  the  more 
pronounced  the  moral  pain  and  the  less  marked  the 
psychic  inhibition.  The  melancholiac  may  commit 
suicide  at  any  period  of  his  illness,  even  during  con- 
valescence, when,  on  account  of  a  real  or  fictitious 
gaiety,  supervision  over  him  is  likely  to  be  relaxed; 

(II)  To  melancholic  wasting,  the  principal  factors  of 
which  are  the  intensity  of  the  moral  pain,  anxiety,  agita- 
tion, and  insufficient  alimentation  occasionedby  a  poor 
condition  of  the  digestive  tract,  orby  a  delusion,  or  by 
a  suicidal  idea; 

(III)  To  some  complication  the  occurrence  of  which 
is  favored  by  the  defective  nutrition  of  the  tissues: 
pneumonia,   influenza,   tuberculosis. 

The  duration  of  the  affection  is  very  variable,  from 
several  weeks  to  a  few  years. 

Treatment. — The  principal  indications  are: 

To  watch  the  patient  with  a  view  to  the  prevention 
of  suicide; 

To  support  his  strength; 

To  calm  agitation  if  there  is  any; 

To  pay  special  attention  to  the  alimentation. 

The  first  three  indications  are  admirably  fulfilled  by 
rest  in  bed. 

Forced  alimentation  is  often  necessary  to  fulfill,  the 
fourth. 

The  moral  pain  may  be  efficaciously  combated  by  the 
administration  of  opium  in  increasing  doses.  One 
may  start  with   15  minims  of  the  tincture  per  day, 

^Kraepelin  Lehrbuch  der  Psychiatrie,  Vol.  II,  p.  457.] 


PSYCHOSES  OF  INVOLUTION.  261 

increase  to  GO  minims  or  more,  and  then  gradually 
reduce  the  quantity  to  the  initial  dose  before  discon- 
tinuing the  treatment. 

Finally,  prolonged  warm  baths  are  often  of  great 
service  in  the  agitated  forms. 

§  2.  Senile  Dementia. 

Senile  dementia  may  be  denned  as  a  peculiar  state 
of  intellectual  enfeeblement,  with  or  without  delusions, 
resulting  from  cerebral  lesions  determined  by  senility. 

Age  is  here,  therefore,  the  great  etiological  factor; 
it  is,  however,  not  the  sole  factor.  Many  individuals 
attain  an  extreme  old  age  without  presenting  any  ap- 
preciable intellectual  disorders;  others,  on  the  contrary, 
have  scarcely  passed  over  the  threshold  of  senility 
when  they  are  already  veritable  dements.  The  effects 
of  age  are  the  more  powerful  and  the  more  precocious 
the  more  marked  the  predisposition.  Heredity,  the 
intoxications  (alcoholism),  overwork,  violent  and  pain- 
ful emotions,  traumatisms,  etc.,  by  diminishing  the 
vitality  of  the  cerebral  cells  render  them  more  suscep- 
tible to  the  influence  of  senility. 

Statistics  furnish  a  rather  small  proportion  of  con- 
genially predisposed  among  senile  dements,  but  this 
is  due  to  the  fact  that  it  is  frequently  impossible  to 
obtain  reliable  family  histories  in  such  cases. 

Senile  dementia  is  rare  before  sixty  years  of  age. 
Alcoholism  sometimes  brings  about  an  analogous  state 
of  intellectual  enfeeblement,  appearing  towards  fifty 
or  fifty-five  years,  which  has  been  designated  by  the 
term  scenium  prcecox.  Such  cases  are  exceptional  if 
we  exclude  ordinary  alcoholic  dementia. 


262  MANUAL  OF  PSYCHIATRY. 

The  onstt  sometimes  follows  some  strong  emotional 
shock,  financial  troubles,  or  a  somatic  affection.  Almost 
always  it  is  insidious,  marked  simply  by  a  change  of 
disposition  and  slight  disorders  of  memory.  When 
fully  established  the  dementia  presents  the  following 
fundamental  elements : 

(a)  Impairment  of  attention  and  sluggishness  of  the 
associations  of  ideas,  readily  demonstrable  b}^  psychom- 
etry,  as  has  been  shown  by  the  experiments  of  Rausch- 
burg  and  Balint.1  (These  authors  performed  their 
experiments  upon  cases  of  simple  senile  dementia  with- 
out delusions.)  A  curious  fact  observed  in  these  experi- 
ments is  that  the  associations  of  ideas  are  almost  always 
determined  by  the  sense  of  the  words,  and  rarely  by 
similarities  of  sound  or  by  rhymes.  It  will  be  re- 
membered that  associations  by  similarities  of  sound 
are  the  result  of  automatic  psychic  activity;  it  seems, 
therefore,  that  the  mental  automatism,  instead  of 
being  exalted,  as  it  is  in  certain  psychoses  (mania), 
is  like  the  voluntary  psychic  activity,  diminished,  at 
least  in  simple  senile  dementia  without  delusions. 

(b)  Inaccurate  and  incomplete  perceptions  of  the  external 
world,  the  consequence  of  which  is  the  production  of 
numerous  illusions  and  of  disorientation  of  place. 

(c)  Disorders  of  memory,  comprising: 

(I)  Amnesia  of  fixation  (anterograde  amnesia),  which 
entails  disorientation  of  time; 

(II)  Amnesia  of  conservation  (retrograde  amnesia), 
which  is  progressive  and  which  most  perfectly  follows 
the  law  of  retrogression; 

1  Ueber  qualitative  und    quantitative,    etc.     Allgem.    Zeitsch.  fur 
Psychiat.,  1900. 


PSYCHOSES  OF  INVOLUTION.  263 

(III)  Illusions  and  hallucinations  of  memory,  which 
form  the  basis  of  imaginary  recollections,  often  absurd 
or  puerile  in  character  and  varying  from  one  instant 
to  another. 

(d)  Impoverishment  of  the  stock  of  ideas:  old  impres- 
sions disappear  and  are  not  replaced  by  new  ones.  This 
is  the  cause  of  the  tiresome  repetitions  in  the  discourses 
of  old  dotards. 

(e)  Loss  of  judgment:  the  patient  does  not  accept 
new  standpoints  of  view.  He  mourns  for  the  good 
old  times  and  shows  a  profound  contempt  for  new 
ideas  which  he  is  incapable  of  assimilating. 

(/)  Diminution  of  affectivity,  morbid  irritability:  hence 
the  indifference  of  senile  dements  for  their  relatives 
and  for  their  interests,  their  unprovoked  outbursts  of 
anger,  their  tyrannical  tendencies,  and  their  occasional 
emotionalism. 

(g)  Automatic  character  of  the  reactions:  from  this 
point  of  view  senile  dements  may  be  divided  into  two 
classes:   the  turbulent  and  the  apathetic. 

The  turbulent  are  always  moving,  intrude  every- 
where, give  unreasonable  or  contradictory  orders,  get 
up  during  the  night  and  wander  about  the  house  with 
a  candle  in  their  hand  at  the  risk  of  starting  a  fire. 
Their  mood  is  either  depressed  or  elated  and  hypo- 
maniacal.  Sexual  excitement,  most  often  purely  psychic, 
is  quite  likely  to  be  associated  with  this  state  and, 
together  with  the  intellectual  enfeeblement,  leads  the 
patient  to  dangerous  acts:  attempts  at  rape,  indecent 
exposures,  etc.1 

By  the  term  exhibitionists  have  been  designated  those  insane 


264  MANUAL  OF  PSYCHIATRY. 

The  apathetic  senile  dements  have  an  indifferent, 
stupid  aspect.  The  patient's  mouth,  half  open,  allows 
the  saliva  to  drool  away;  he  remains  motionless  upon 
the  chair  where  he  has  been  placed;  he  is  docile,  obe- 
dient, and  very  suggestible.  When  in  the  hands  of 
unscrupulous  persons,  he  allows  himself  without  pro- 
testation to  be  swindled  and  maltreated,  and  uncon- 
sciously yields  to  inveiglements  for  imprudent  dis- 
posal of  his  property. 

In  advanced  stages  of  the  disease  the  turbulent  as 
well  as  the  apathetic  senile  dements  frequently  become 
filthy,  often  soiling  and  wetting  themselves. 

Sleep  is  diminished  and  often  even  absent  in  the  ex- 
cited forms.  On  the  other  hand,  constant  somnolence 
is  frequent  in  the  apathetic  cases. 

Together  with  the  dementia  there  are  the  regular 
signs  of  senility:  the  skin  is  wrinkled  and  discolored; 
the  hairy  system  is  undergoing  atrophy;  the  patellar 
reflexes  are  sometimes  abolished,  but  more  frequently 
exaggerated;  the  pupils  are  slightly  myotic  and  paretic; 
arcus  senilis  is  well  marked;  there  is  hypoaBsthesia  of 
all  the  senses;  the  movements  are  awkward  and  uncer- 
tain; there  is  diminution  of  the  muscular  power;  senile 
tremors  affect  the  entire  body  and  especially  the  head; 
where  they  consist  of  coarse  oscillations. 

The  cardio-vascular  symptoms  are  of  great  importance. 
They  are  dependent  upon  arteriosclerosis  and  myo- 
carditis; the  pulse  is  rapid  and  feeble,  the  heart-sounds 
are  muffled,  the  arteries  are  hard  and  sinuous,  like  a 

who   have   a  morbid   tendency   to   exhibit   publicly   their  genital 
organs. 


PSYCHOSES  OF  INVOLUTION.  265 

pipe-stem.  These  lesions  are  largely  responsible  for 
the  disorders  of  the  cerebral  nutrition  and  are  the 
cause  of  such  formidable  complications  as  cerebral 
hemorrhage  and  softening. 

The  signs  of  interstitial  nephritis  are  frequently 
observed. 

The  appetite  is  diminished,  or,  on  the  contrary,  it 
may  be  exaggerated  to  a  degree  constituting  voracity. 
In  the  latter  case  the  patients  should  be  carefully 
dieted  to  prevent  grave  gastro-intestinal  disturbances. 

Delusional  forms. — The  delusions  bear  the  stamp  of 
dementia:  they  are  absurd,  changeable,  and  present 
little  or  no  tendency  to  systematization.  They  may 
be  of  the  following  varieties: 

(a)  Ideas  of  persecution,  which  in  their  mildest  form 
manifest  themselves  by  mere  suspiciousness,  which  is 
always  frequent  in  old  persons.  Their  form  is  varied: 
ideas  of  poisoning,  of  theft,  of  jealousy,  fear  of  being 
killed,  etc. 

The  persecutory  ideas  are  the  ones  that  are  most 
likely  to  become  systematized,  though  the  systematiza- 
tion is  very  imperfect,  and  to  be  accompanied  by  hallu- 
cinations, chiefly  of  hearing  and  of  vision.  Sometimes 
these  delusions  appear  long  before  any  evidences  of 
dementia,  constituting  the  presenile  persecutory  delirium 
(Kraepelin). 

(b)  Melancholy  ideas  of  all  possible  types:  ideas  of 
self -accusation,  of  ruin,  etc.  Ideas  of  negation  are  very 
frequent. 

(c)  Ideas  of  grandeur,  which  are  at  times  absurd, 
resembling  those  of  general  paretics. 

The  delusions  are  associated  with  a  corresponding 


266  MANUAL  OF  PSYCHIATRY. 

state  of  the  emotions  and  of  the  reactions.  Three  princi- 
pal forms  of  delusional  senile  dementia  may  be  dis- 
tinguished : 

(1)  Persecutory  form:  ideas  of  persecution;  reactions 
of  self-defense  which  may  at  times  be  violent. 

(2)  Melancholic  form:  melancholy  ideas,  moral  pain, 
depression,  anxiety,  suicidal  ideas. 

(3)  Maniacal  form:  euphoria,  ideas  of  grandeur, 
variable  moods,  impulsive  reactions,  sometimes  flight 
of  ideas,  erotic  tendencies,  etc. 

Senile  dementia  is  sometimes  marked  by  acute  attacks 
characterized  by  complete  disorientation  and  hallu- 
cinations, closely  resembling  certain  phases  of  general 
paresis,  and  especially  delirium  tremens  [senile  delirium]. 
These  attacks,  usually  very  brief,  terminate  either  in 
death  or  in  a  return  to  the  previous  condition.  They 
may  occur  in  old  persons  independently  of  any  intellec- 
tual enfeeblement  (Wernicke). 

The  principal  complications  of  senile  dementia  are: 

Apoplectic  and  sometimes  epileptic  seizures  (senile 
epilepsy),  hemiplegia,  aphasic  phenomena,  etc. 

Alcoholism  in  the  form  of  episodic  accidents  (delirium 
tremens)  or  of  alcoholic  dementia  may  be  associated 
with  senile  dementia. 

The  prognosis  is  fatal.  The  affection  always  follows 
a  progressive  course.  Remissions  are  very  rare  and 
never  complete.  Death  usually  supervenes  at  the  end 
of  from  three  to  five  years,  as  a  result  of  senile  cachexia, 
of  some  intercurrent  disease  (pneumonia),  or  of  apoplexy. 

Not  all  psychoses  occurring  at  an  advanced  age  are 
senile  dementia.  Old  men  present  attacks  of  manic 
depressive    insanity,    paranoia,   and    other    psychoses 


PSYCHOSES  OF  INVOLUTION.  267 

which  differ  in  no  way  from  those  observed  in  younger 
people.1 

The  diagnosis  is  to  be  based  upon  the  pathognomonic 
features  of  the  dementia. 

Affective  melancholia  and  manic  depressive  insanity 
may  be  distinguished  by  the  absence  of  intellectual 
enfeeblement,  by  the  conservation  of  the  lucidity,  and 
by  the  intensity  of  the  affective  phenomena, — moral 
pain  or  euphoria. 

General  paresis  may  be  differentiated  by  the  more 
rapid  development  of  the  dementia  and  by  its  special 
physical  signs. 

Alcoholic  dementia  shows  the  physical  signs  of  chronic 
alcoholism:  cramps,  muscular  tremors,  gastric  dis- 
orders, etc.  Senile  dementia  and  alcoholic  dementia 
may  exist  together. 

The  anatomical  lesions  arise  from  a  process  of  wear 
and  atrophy :  atheroma  of  the  cerebral  arteries,  thicken- 
ing of  the  meninges,  diminution  of  the  weight  of  the 
brain,  which  may  sometimes  fall  below  1000  grams; 
thinning  of  the  cortex;  diminution  of  the  number  of 
nerve-cells,  chromatolysis,  pigmentary  degeneration, 
atrophy;  disappearance  of  a  large  number  of  tangential 
fibers. 

The  treatment,  purely  symptomatic,  consists  chiefly 
in  hygienic  measures.  Commitment  is  but  seldom 
necessary.  The  majority  of  cases  are  best  treated  in 
special  asylums  for  the  aged  or  in  private  homes. 

1  Thivet.  Contribution  a  V etude  de  la  folie  chez  les  vieillards. 
These  de  Paris.  1889. — Regis.  Psychoses  de  la  vieillesse.  Ann. 
med.  psych.,  March-April  1897. — Ritti.  Les  psychoses  de  la 
vieillesse.     Congres  des  medecins  alienistes  et  neurologistes,  1896. 


CHAPTER  XII.1 
MANIC  DEPRESSIVE   INSANITY.1 

Manic  depressive  insanity  is  manifested  in  attacks 
presenting  a  double  characteristic:  a  tendency  towards 
recovery  without  intellectual  enfeeblement  and  a  ten- 
dency towards  recurrence.  From  a  symptomatic  stand- 
point the  attacks  are  of  three  types;  which  I  shall  de- 
scribe successively: 

Manic  type; 

Depressed  type; 

Mixed  type. 

§  1 .  Manic  Type. 

Mania  presents  itself  in  three  principal  forms :  simple 
mania,  delusional  mania,  and  confused  mania.  We 
shall  first  study  simple  mania,  which,  more  clearly 
than  the  other  forms,  exhibits  the  following  four  funda- 
mental symptoms  of  the  disease: 

Flight  of  ideas; 

Morbid  euphoria  and  irritability; 

Impulsive  character  of  the  reactions;  ■ 

Motor  excitement. 

1  Kraepelin.  Lehrbuch  der  Psychiatrie,  Vol.  II. — Weygandt. 
Ueber  das  manisch-depressives  Irresein.  Berlin,  klin.  Woch.,  1901, 
Nos.  4  and  5. 

268 


MANIC  DEPRESSIVE  INSANITY.  269 

Simple  mania.  —  Prodromata.  —  The  phenomena  of 
maniacal  excitement  are  constantly  preceded  by  a 
period  of  depression  associated  with  a  diminution  of 
psychic  activity,  which  sometimes  amounts  to  a  veri- 
table melancholic  state.  Later  on  we  shall  see  the 
importance  of  this  prodromal  period  as  an  argument 
for  the  unity  of  manic  depressive  insanity. 

External  aspect. — The  face  of  the  maniac  is  flushed, 
the  eyes  brilliant,  the  expression  happy  and  animated. 
The  manner  and  gestures  indicate  a  state  of  ease  con- 
trasting often  with  the  usual  timidity  of  the  patient. 
The  dress  is  showy,  ridiculous,  and  ornamented  with 
gaudy  trinkets;  the  clothes  are  disordered,  perhaps 
put  on  inside  out.  In  women  a  bodice  excessively 
decollete  and  the  skirt  raised  too  high  show  also  the 
erotic  tendencies. 

Intellectual  disorders. — The  lucidity  is  perfect,  the 
orientation  and  the  memory  are  intact. 

The  attention,  very  mobile,  is  distracted  by  all  external 
impressions. 

The  associations  of  ideas,  uncontrolled,  are  formed 
at  random  from  similarities  of  sound,  superficial  resem- 
blances, coexistences  in  time  and  space,  etc.  Flight 
of  ideas  is  here  encountered  in  its  typical  form. 

These  two  symptoms,  mobility  of  attention  and 
flight  of  ideas,  are,  as  we  have  already  seen,  an  expression 
of  the  enfeeblement  of  the  normal  psychic  activity  and 
of  the  predominance  of  mental  automatism.  Under 
these  conditions  the  capacity  for  intellectual  labor 
is  diminished. 

The  judgment,  which  is  largely  dependent  upon  asso- 
ciations   of    ideas,    is    always    profoundly    disordered. 


270  MANUAL  OF  PSYCHIATRY. 

Though  occasionally  the  patient  surprises  one  by  the 
accuracy  of  his  observation,  it  is  always  the  result 
of  a  sort  of  automatic  appreciation  bearing  upon  some 
isolated  fact.  But  since  judgment  necessitates  the 
systematic  grouping  of  quite  a  considerable  number 
of  ideas,  it  is  here  either  absent  or  at  least  impaired. 
A  maniac  who  notices  some  slight  defect  in  the  dress 
of  the  examiner  is  incapable  of  appreciating  the  impor- 
tance of  an  event  or  of  an  act. 

Affective  disorders. — These  consist  in  morbid  euphoria 
and  irritability. 

The  euphoria  is  often  very  marked.  Many  patients 
after  recovery  declare  that  they  had  never  felt  as  happy 
as  they  did  during  the  attack.  The  maniac  is  pleased 
with  everything,  and  the  contrast  is  particularly  strik- 
ing when  the  excitement  follows  a  period  of  depression 
(insanity  of  double  form).  The  most  imperturbable 
optimism  replaces  the  pessimism  of  past  days.  Of 
disease  insight  there  is  no  question  at  all;  the  subject 
"  never  before  felt  so  well; "  if  he  is  "  somewhat  nervous  " 
the  fault  is  with  his  relatives,  the  physicians,  or  the 
nurses,  who  constantly  interfere  with  him.  With  his 
intelligence  and  activity  he  could  "  easily  conduct 
important  and  gigantic  enterprises. "  If  he  were 
allowed  liberty  of  action,  he  would  show  to  everybody 
what  he  is  capable  of. 

Sad  impressions  are  dismissed  with  a  vague  remark 
or  a  joke.  A  maniac,  reminded  of  the  loss  of  his  fortune 
in  a  fire  (which  in  his  case  was  the  cause  of  the  disease), 
replied  laughingly:  "Money  does  not  bring  happiness, 
and  besides  I  shall  have  earned  twice  as  much  in  six 
months  from  now." 


MANIC  DEPRESSIVE   INSANITY.  271 

The  optimism,  however,  is  never  as  absurd  as  that 
of  general  paretics  or  of  senile  dements.  Dumas  cites 
the  case  of  a  general  paretic  who,  reminded  of  the 
recent  death  of  his  two  little  daughters,  replied:  "  Well, 
well!  I  shall  resuscitate  them."  A  maniac  would 
never  have  given  such  an  answer. 

The  irritability  is  evident  in  the  violent  outbursts  of 
anger  which  occur  on  the  slightest  provocation.  The 
maniac  will  bear  no  contradictions  and  will  accept  no 
suggestions. 

The  moral  sense  is  always  diminished;  the  sense  of 
propriety  is  greatly  affected.  The  maniac  is  cynical, 
dishonest,  and  mischievous.  "He  lies,  cheats,  and 
steals  without  the  least  scruple.  He  allows  himself 
anything  that  in  others  he  would  condemn  "  (Wernicke). 
Quite  frequently  he  will  tease  and  mock  others.  If  in 
the  midst  of  his  incoherent  speech  some  pointed  or 
amusing  remark  occurs,  it  is  always  at  the  expense  of 
others. 

Erotic  tendencies  form  an  integral  part  of  the  picture: 
the  patients  abandon  themselves  to  them  without 
shame.  Men  previously  exemplary  in  habits  go  around 
with  prostitutes.  Young  girls  very  reserved  in  their 
manner  normally  offer  themselves  to  everybody. 

One  frequently  sees  maniacs  indulging  in  alcoholic 
excesses. 

The  patient  is  incapable  of  appreciating  the  signifi- 
cance of  his  actions  either  before  or  after  they  are 
accomplished.  The  most  deprecable  acts  are  dis- 
played with  complacency  and  become  the  object  of 
cynical  pleasantries;  compunction  and  scruples  are 
absent. 


272  MANUAL  OF  PSYCHIATRY. 

Reactions. — The  erethism  of  the  psychomotor  centers, 
constant  in  mania,  gives  rise  to  maniacal  excitement 
the  elements  of  which  are  the  imperative  want  of 
movement,  the  abnormal  rapidity  of  the  reactions,  and 
the  impulsive  character  of  the  acts. 

Maniacal  excitement  always  has  a  psychic  origin 
(Wernicke);  the  acts,  though  impulsive,  are  dependent 
upon  an  appreciable  cause  and  have  a  definite  purpose. 

This  excitement  often  assumes  the  aspect  of  morbid 
activity  which,  lacking  in  logical  sequence,  remains 
unproductive  when  it  does  not  become  harmful.  The 
maniac  every  instant  leaves  one  task  to  begin  another, 
or  undertakes  tasks  for  which  he  possesses  neither  the 
necessary  aptitude  nor  the  qualifications.  A  farmer, 
fifty  years  of  age  and  scarcely  able  to  read  or  write, 
wanted  to  undertake  the  study  of  Hebrew  "to  unite 
1;he  Jews  and  Protestants." 

The  maniac  is  strongly  inclined  to  intrude  into  the 
affairs  of  others,  causing,  as  might  be  expected,  much 
trouble.  He  offers  his  advice  and  assistance  to  every- 
body. In  the  asylum  he  accompanies  the  physician 
on  his  rounds,  makes  diagnoses,  and  prescribes  treat- 
ment. Often  he  tries  to  assist  the  nurses,  who  find  it 
very  difficult  to  moderate  his  zeal. 

In  the  more  marked  degrees  the  excitement  leads  the 
patient  to  many  eccentricities.  He  removes  his  cloth- 
ing, replaces  it;  executes  pirouettes  and  dangerous 
leaps;  sings  obscene  songs;  performs  grimaces  and 
contortions  for  the  amusement  of  his  spectators;  and 
frequently  annoys  others  in  a  thousand  ways. 

The  conversation  is  animated,  strewn  with  eccentric 
remarks,  strange  words,  and  puns.    The  language  may 


MANIC  DEPRESSIVE  INSANITY.  273 

be  either  profane  and  obscene  or  marked  by  a  labored 
refinement.  The  tone  may  be  jocose  or  solemn,  accom- 
panied by  the  gestures  of  a  gamin  or,  on  the  contrary, 
by  those  of  a  commander  or  a  preacher.  There  is  often 
a  veritable  logorrhoea. 

The  writing  presents  analogous  characteristics.  Volu- 
bility and  prolixity  are  manifested  by  whole  pages 
scribbled  within  a  few  minutes.  The  lines  cross  each 
other  in  every  direction,  the  letters  are  large  in  size, 
and  capitals  and  flourishes  are  abundant. 

The  discourse  is  conducted  at  random:  reflections 
upon  questions  of  transcendental  philosophy  as  well  as 
upon  thoss  of  dress  or  cooking;  slander  and  intimate 
confidences,  extravagant  projects  and  erotic  proposals. 
The  maniac  conceals  nothing.  Mangan  has  very  aptly 
remarked:  "II  est  tout  en  dehors. " 

Physical  symptoms. — We  find  in  mania  the  physical 
symptoms  which,  as  we  have  already  seen,  are  asso- 
ciated with  morbid  euphoria:  the  general  nutrition 
and  the  peripheral  circulation  are  active,  the  pulse  is 
full  and  rapid,  respiration  is  deep  and  accelerated,  the 
appetite  is  good,  and  the  weight  increases. 

Sleep  is  diminished,  occasionally  altogether  absent; 
but  in  spite  of  the  insomnia  the  patient  experiences 
no  fatigue. 

Often  in  women  the  menses  are  suspended,  and 
their  return  announces  the  approach  of  recovery. 
When  they  persist  through  the  attack  their  appear- 
ance is  likely  to  provoke  a  recrudescence  of  the  excite- 
ment. 

Delusional  mania. — The  fundamental  symptoms  are 
the  same  as  those  of  simple  mania.     The  excitement 


274  MANUAL  OF  PSYCHIATRY. 

may  be  more  marked  and  the  lucidity  perhaps  tran- 
sitorily disturbed. 

The  delusions  are  usually  mobile  and  consist  in  ideas 
of  grandeur. 

The  most  varied  delusions  follow  each  other,  modified 
every  instant  by  external  impressions.  The  patient 
assumes  all  the  titles  mentioned  to  him:  he  is  in  turn 
pope,  physician,  and  admiral.  Occasionally  the  delu- 
sions are  referred  to  the  past  and  take  the  form  of  imag- 
inary recollections:  a  shoemaker  pretended  to  have 
directed  an  expedition  to  the  North  Pole. 

The  patient  often  transforms  the  surroundings  in 
which  he  finds  himself.  A  maniac  called  the  head 
nurse  of  the  service  where  he  was  treated  the  chief  of 
his  military  station,  the  physician  he  called  the  prince 
of  Sagan. 

The  costume  corresponds  with  the  delusions:  the 
patients  clothe  themselves  in  fantastic  uniforms,  cover 
their  chests  with  decorations,  comb  their  hair  in  the 
style  of  Bonaparte,  etc. 

Sometimes  one  delusion  persists  and  becomes  fixed 
during  the  entire  duration  of  the  attack  in  the  midst 
of  more  mobile  accessory  delusions:  a  modest  business 
agent  for  several  months  proclaimed  himself  to  be  the 
President  of  France,  and  considered  the  physicians  and 
nurses  as  his  "grand  staff." 

The  maniac  never  has  absolute  faith  in  his  delusions. 
His  conviction  is  easily  shaken.  Often  even  he  himself 
only  half  believes  in  the  pompous  titles  that  he  gives 
himself;  his  delusions  are  a  sort  of  pleasantry  with 
which  he  amuses  himself  and  with  which  he  mystifies 
his  friends. 


MANIC  DEPRESSIVE  INSANITY.  275 

Some  ideas  of  persecution,  often  bearing  upon  the 
deprivation  of  liberty,  may  occur  in  addition  to  the 
ideas  of  grandeur. 

Hallucinations  are  rare  and  fleeting.  On  the  other 
hand,  illusions  are  frequent  and  lasting;  they  often 
assume  the  form  of  false  recognitions:  the  patient  is 
apt  to  believe  himself  surrounded  by  his  acquaintances 
and  by  familiar  objects. 

In  grave  forms,  during  paroxysms,  the  consciousness 
at  times  undergoes  a  certain  degree  of  clouding  and  the 
period  of  illness  leaves  but  a  very  vague  impression,  or 
none  at  all,  upon  the  memory. 

Confused  mania. — Clouding  of  consciousness  is  here 
permanent.  The  attack  begins  suddenly  or  after  a 
short  prodromal  period,  characterized  from  the  beginning 
by  complete  disorientation,  very  great  excitement,  and 
totally  incoherent  delusions.  Numerous  hallucinations 
always  accompany  the  delusions.  The  form  of  the 
delusions  is  very  variable:  in  confused  mania  are  often 
encountered  ideas  of  grandeur,  of  persecution,  and 
occasionally,  as  an  episodic  accident,  some  melancholy 
delusions. 

Even  when  the  grandiose  ideas  predominate  euphoria 
is  very  frequently  absent.  The  cause  of  this  anomaly 
probably  exists  in  the  purely  automatic  character  of  all 
the  psychic  manifestations.  To  provoke  a  sense  of 
pleasure  the  activity  must  be  conscious,  that  is  to  say, 
accompanied  by  a  voluntary  effort,  no  matter  how 
slight;  whereas  in  confused  mania  the  fragmentation 
of  tha  personality  is  such  that  the  flight  of  ideas  is 
effected  with  extreme  facility:  the  effort  is  absent  and 
with  it  the  euphoria. 


276  MANUAL  OF  PSYCHIATRY. 

The  patient  loses  weight,  the  features  become  drawn 
out,  the  pulse  grows  small  and  depressible.  The 
intensity  of  the  excitement  permits  of  no  regular 
alimentation. 

Filthy  tendencies  are  frequent:  unless  watched  con- 
stantly the  patient  is  apt  to  smear  the  walls,  his  bed, 
his  clothing,  and  his  own  body  with  faeces.  Some  will 
even  eat  faeces. 

The  attack  may  terminate  in  death,  either  from 
general  exhaustion  or  from  some  inter  current  complica- 
tion: pneumonia,  suppuration  occasioned  by  trauma- 
tism, etc. 

General  course,  duration,  and  prognosis  of  a  maniacal 
attack. — The  course  of  mania  is  capricious.  In  a  general 
way  it  may  be  represented  by  a  curve  which  at  first 
ascends,  then  remains  horizontal  for  a  longer  or  shorter 
time,  and  finally  gradually  descends.  But  this  curve, 
far  from  being  regular,  is  interrupted  by  oscillations 
indicating  either  sudden  exacerbations  or  attenuations 
of  the  symptoms,  or  even  true  remissions  the  duration 
of  which  may  vary  from  several  minutes  to  several  days. 
The  progress  of  the  attack  may  also  be  interrupted  by 
phenomena  of  depression  which  are  sometimes  quite 
marked,  though  very  brief  in  duration.  As  we  shall 
see  later  on,  this  fact  contributes  to  the  proof  of  the 
homogeneity  of  manic  depressive  insanity. 

The  duration  of  the  attack,  whatever  its  form,  cannot 
be  predicted.  Some  attacks  terminate  in  a  few  hours, 
deserving  a  place  among  the  transitory  insanities,  others 
continue  for  several  years. 

The  prognosis,  leaving  out  the  cases  in  which  life  is 
endangered  by  the  intensity  of  the  excitement  or  by 


MANIC  DEPRESSIVE  INSANITY.  277 

Borne  complication,  is  favorable  as  to  the  termination 
of  the  attack  itself.  Recovery  with  restitutio  ad  inte- 
grum is  the  rule. 

Treatment. — Rest  in  bed  in  these  cases  performs 
miracles.  It  is  well  accepted  and  easily  instituted. 
Unfortunately  it  is  not  possible  at  present  to  say  whether 
or  not  it  actually  shortens  the  duration  of  the  disease. 

§  2.  Depressed  Type. 

The  fundamental  symptoms  of  the  depressed  type 
of  manic  depressive  insanity  are: 

Psychic  inhibition; 

A  painful  emotional  state  associated  with  indifference; 

Aboulia. 

As  in  the  case  of  mania,  we  distinguish  here  three 
forms:   simple,  delusional,  and  stuporous  depression. 

Simple  depression. — Onset. — Usually  insidious,  pre- 
ceded by  ill-defined  prodromata,  such  as  general  prostra- 
tion, insomnia,  anorexia,  discouragement. 

The  external  aspect  of  the  patient  is  one  of  sadness, 
listlessness,  and  indifference.  The  features  are  drawn 
out,  the  head  bowed  down  upon  the  chest,  the  arms 
hanging  inertly  at  the  sides  or  resting  upon  the  knees. 
The  general  bearing  is  slouchy. 

Intellectual  disorders. — The  psychic  inhibition  deter- 
mines a  very  marked  weakening  of  the  attention  and 
a  considerable  sluggishness  of  the  associations  of  ideas. 
All  intellectual  exertion,  such  as  the  narration  of  an 
event  well  known  to  the  patient  or  a  small  calculation, 
is  impossible  or  can  be  accomplished  only  after  repeated 
and  painful  efforts.  Though  the  lucidity  is  intact, 
the  perceptions  are  incomplete,   uncertain,   and  often 


278  MANUAL  OF  PSYCHIATRY. 

inaccurate.  Everything  appears  to  the  patient  strange 
or  unrecognizable:  persons,  objects,  and  even  his  own 
body.  Here  we  have  a  condition  bordering  upon 
delirium.  Another  step  and  we  have  illusions  and 
hypochondriacal  ideas. 

The  disorders  of  judgment  are  less  marked  than  in 
mania.  The  patient  is  quite  frequently  conscious  of 
his  condition  to  some  extent.  He  feels  that  he  is 
changed,  ill,  and  it  seems  to  him  that  his  mind  is 
paralyzed. 

Affective  disorders. — The  mood  is  sad,  gloomy,  pessi- 
mistic. The  patient  emits  monotonous  groans.  While 
the  maniac  brings  disorder  into  a  service  of  an  asylum, 
the  melancholiac  brings  depression  and  gloom. 

The  moral  ancBsthesia  is  always  very  marked,  and 
sometimes  the  patient  is  conscious  of  it.  He  com- 
plains of  having  become  indifferent  towards  every- 
thing, of  experiencing  no  affection. 

Upon  this  general  state  of  depression  and  sadness 
may  be  engrafted  a  spell  of  anxiety,  usually  transient. 
In  no  case,  however,  is  the  moral  pain  so  intense  as 
in  affective  melancholia.  The  depressed  phases  of 
manic  depressive  insanity  correspond  to  passive  de- 
pression. 

Disorders  of  the  reactions. — These  all  result  from  the 
marked  aboulia  present  in  such  cases,  which  is,  in  its 
turn,  a  manifestation  of  the  psychic  paralysis. 

The  execution  of  the  simplest  act  necessitates  an 
effort  so  great  at  times  that  the  patient  gives  up  the 
attempt.  As  in  the  case  of  the  moral  indifference,  the 
patient  may  be  conscious  of  the  aboulia. 

Together  with  the   insufficiency  of  perception,   the 


MANIC  DEPRESSIVE  INSANITY.  279 

aboulia  brings  about  doubt.  The  patient  lives  in 
constant  indecision  and  uncertainty. 

Conversation  with  the  patient  is  most  unsatisfactory. 
Often,  in  spite  of  all  persistence,  the  patient  remains 
mute  or  responds  by  an  unintelligible  murmur  or 
whispering.  The  mental  synthesis  necessary  for  an 
elaboration  of  a  response  is  impossible  for  him.  In  the 
milder  cases,  to  some  very  simple  questions  repeated 
several  times  brief  answers  are  obtained. 

The  voice  is  scarcely  audible,  the  speech  is  indistinct. 
The  same  words  are  constantly  reiterated,  expressing 
doubt,  indecision,  sadness:  "'What  is  this? ...  What  is 
going  to  happen?  . . .  This  is  frightful.  " 

The  writing  is  slow;  letters  are  poorly  formed,  small, 
disconnected. 

Physical  symptoms.  —  These  have  already  been  de- 
scribed in  connection  with  morbid  depression.  I  shall 
review  them  briefly. 

The  peripheral  circulation  is  sluggish,  the  extremities 
cold  and  cyanotic.  The  pulse  is  small,  of  low  tension, 
sometimes  slowed.  The  heart-sounds  are  muffled. 
The  temperature  may  be  subnormal. 

The  coated  tongue,  fetid  breath,  a  sense  of  weight 
in  the  stomach,  constipation,  and  anorexia  reveal  the 
poor  state  of  the  digestive  functions. 

Loss  of  weight  is  a  constant  phenomenon.  The 
return  to  the  normal  weight  always  indicates  the  end 
of  the  attack. 

Sleep  is  diminished,  unrefreshing,  disturbed  by  night- 
mares. 

Often  the  patient  complains  of  headache  and  of  vague 
pains  in  the  limbs. 


280  MANUAL  OF  PSYCHIATRY. 

The  cutaneous  sensibility  is  blunted. 

The  tendon  reflexes  are  often  diminished  and  some- 
times abolished. 

Delusional  depression.  —  Always  secondary  to  the 
emotional  state,  the  delusions  are  preceded  by  a  longer 
or  shorter  period  of  simple  depression. 

They  present  the  usual  characters  of  depressive  ideas 
and  assume  the  most  varied  forms:  hypochondriacal 
ideas,  ideas  of  humility,  of  self-accusation,  or  of  ruin, 
fear  of  terrible  punishment,  etc.  Fixed  ideas  are 
frequent. 

Occasionally  these  delusions  are  quite  absurd  and 
resemble  those  of  dementia.  In  other  cases  they  are 
associated  with  ideas  of  persecution  and  become  sys- 
tematized to  a  certain  extent,  constituting  a  systema- 
tized delirium  of  self-accusation  or  of  persecution,  as 
the  case  may  be. 

Hallucinations  are  rare.  The  least  exceptional  are 
those  of  vision. 

Illusions,  though  less  numerous  than  in  mania,  are, 
however,  quite  frequent.  Following  the  general  rule, 
the  psycho-sensory  disorders  are  the  expression  of  the 
delusional  preoccupations. 

The  lucidity  may  be  transitorily  affected.  The  usual 
inertia  is  sometimes  effaced  and  replaced  by  a  certain 
degree  of  excitement.  In  other  cases  it,  on  the  con- 
trary, becomes  more  marked,  giving  rise  to  a  transient 
stupor. 

Depression  with  stupor. — This  form  rarely  begins 
as  such;  it  is  usually  preceded  by  simple  or  delusional 
depression. 

The    characteristic    trait    here    is    complete    inertia 


MANIC  DEPRESSIVE  INSANITY.  281 

associated  with  absolute  indifference  to  all  external 
impressions.  The  physiognomy  is  stupid,  sometimes 
expressing  fear. 

The  usual  physical  symptoms  of  depression  are  here 
very  pronounced. 

Almost  always  the  patient  becomes  negligent  and 
filthy,  wetting  and  soiling  his  bed. 

In  some  cases  may  be  observed  a  tendency  to  cata- 
leptoid  attitudes. 

The  stupor  may  have  one  of  two  different  origins: 

(1)  The  psychic  inhibition  reaching  an  extreme  limit 
of  intensity  suppresses  all  conscious  and  voluntary 
intellectual  activity.  The  indifference  is  complete,  the 
moral  pain,  on  the  contrary,  becoming  nil;  in  fact 
the  inhibition  is  never  perceived  as  a  painful  phe- 
nomenon unless  the  mind  seeks  to  overcome  it;  in 
the  stupor  the  arrest  of  the  psychic  functions  is  so 
pronounced  that  the  patient  makes  no  attempt  to 
react. 

(2)  The  patient's  mind  is  occupied  by  an  intense, 
frightful  delirium.  There  is  an  endless  succession  of 
terrifying  hallucinations  analogous  to  those  of  epileptic 
delirium.  The  patient  is  in  a  frightful  nightmare  which 
completely  absorbs  him,  rendering  him  insensible  to 
impressions  of  the  external  world. 

Course,  duration,  and  prognosis  of  the  depressed  type 
of  manic  depressive  insanity. — As  in  mania,  the  course  is 
irregular,  interrupted  by  temporary  remissions  and 
exacerbations.  The  duration  varies  within  very  wide 
limits,  from  a  few  days  to  several  months  or  even  years ; 
the  prognosis  is  always  favorable  for  recovery  from  the 
attack,  except  in  cases  of  grave  somatic  complications. 


282  MANUAL  OF  PSYCHIATRY. 

Physical  improvement,  especially  an  increase  in  weight, 
usually  indicates  convalescence. 
The  treatment  consists  in: 

(1)  Sustaining  the  forces  of  the  patient  by  rest, 
especially  rest  in  bed,  and  by  a  plentiful  and  nutritious 
diet; 

(2)  Careful  watching  to  prevent  suicide; 

(3)  Calming  agitation,  when  present,  by  the  usual 
procedures ; 

(4)  Combating  the  gastric  disorders  and  the  phenom- 
ena of  autointoxication  that  are  so  frequent  in  states 
of  depression. 

Moral  treatment  in  the  form  of  suggestion,  moderate 
physical  and  intellectual  labor,  etc.,  is  of  great  service 
during  convalescence,  but  is  absolutely  contraindicated 
during  the  entire  acute  period  of  the  disease. 

§  3.  Mixed  Types. 

Attacks  of  mixed  form,  properly  so  called. — Kraepe- 
lin  has  brought  to  light  the  features  of  these  cases  which 
are  more  frequent  than  is  generally  believed  and  in 
which  the  symptoms  of  excitement  and  of  depression 
appear  in  the  same  patient  at  the  same  time. 

In  one  group  of  cases  the  usual  signs  of  depression 
are  associated  with  extreme  mobility  of  the  attention 
and  a  veritable  flight  of  ideas.  The  patients  complain 
that  the  direction  of  their  thoughts  escapes  them. 
"My  head  always  wanders,"  said  one  such  patient; 
"I  cannot  fix  my  attention  upon  anything."  Occa- 
sionally there  is  melancholic  hgorrhcea.  Many  de- 
pressed   patients    show    a    surprising   prolixity,    con- 


MANIC  DEPRESSIVE  INSANITY.  283 

stantly  giving  vent  to  incoherent  lamentations  about 
their  unhappy  lives.1 

In  a  second  group  of  cases  the  disease  presents  itself 
with  the  characteristics  of  maniacal  stupor  (Kraepelin). 
The  psychic  paralysis  is  associated  with  more  or  less 
pronounced  excitement:  the  patient  is  constantly 
moving,  disarranges  his  bed,  tears  his  clothes,  soils  the 
walls  of  his  room,  and  at  the  time  shows  such  complete 
intellectual  obtuseness  that  even  the  simplest  questions 
put  to  him  remain  unanswered. 

Finally,  in  a  third  group  the  inhibition  is  less  pro- 
nounced, and  the  elated  mood  of  mania  is  replaced  by 
an  uneasy,  gloomy,  irritable  one,  the  basis  of  which  is 
the  sadness,  like  in  the  depressed  type. 

The  mixed  type  sometimes  persists  through  the  entire 
duration  of  the  attack.  More  frequently  it  is  met  with 
in  the  transition-periods  of  circular  insanity,  where  the 
patient  wavers,  so  to  speak,  between  excitement  and 
depression. 

Attacks  of  double  form. — The  attack  is  here  consti- 
tuted by  two  periods:  a  period  of  depression  and  a 
period  of  excitement.  It  usually  begins  with  the 
depression. 

The  transition  from  depression  to  excitement  occurs 
either  suddenly, — a  patient  goes  to  bed  a  melancholiac 
and  rises  the  next  morning  a  maniac, — or  gradually, 
with  an  intervening  period  of  the  mixed  form  of  manic 
depressive  insanity,  as  mentioned  above.  The  psycho- 
motor inhibition  gradually  becomes  less  prominent  and 
is  replaced  by  excitement ;  flight  of  ideas  and  logorrhcea 
appear.     Finally  the  sadness  disappears  and  the  mani- 

1  Kraepelin.     Loc.  cit. ,  p.  545. 


284  MANUAL  OF  PSYCHIATRY. 

acal   elation   replaces   it.     When   a   maniac   falls   into 
depression  the  same  transition  occurs  inversely. 

§  4.  General  Course. — Prognosis  of  Manic  Depres- 
sive Insanity.  —  General  Considerations.  — 
Treatment. 

Attacks  of  manic  depressive  insanity  present  a 
very  marked  tendency  to  recur.  According  to  the 
particular  forms  assumed  by  the  successive  attacks, 
several  types  of  manic  depressive  insanity  are  dis- 
tinguished. 

(A)  Periodic  insanities: 
(a)  Recurrent  mania; 

(6)  Recurrent  melancholia. 

(B)  Alternating  insanity. 

(C)  Circular  insanity. 

(D)  Irregular  forms. 

(A)  Periodic  insanities. — (a)  Recurrent  mania. — The 
attacks  always  present  the  maniacal  type  and  are  sepa- 
rated from  each  other  by  normal  periods.  The  number 
of  attacks  and  the  duration  of  the  normal  periods  vary 
greatly.  Some  patients  have  but  two  or  three  attacks 
during  their  lives;  it  is  altogether  exceptional  for  an 
individual  to  have  but  one  attack,  at  least  when  his 
life  is  a  long  one.  In  all  likelihood  non-recurring 
mania  does  not  exist. 

In  other  cases  the  attacks  follow  each  other  at  brief 
intervals  and  with  a  certain  regularity. 

Excitement  Excitement  Excitement 

Normal     / \  Normal/ XNormal/ \       Normal 

State  State  State  State 

SCHEME  I.     RECURRENT  MANIA. 


MANIC  DEPRESSIVE  INSANITY.  285 

(b)  Recurrent  melancholia. — Less  frequent  than  the 
preceding,  this  form  is,  so  to  speak,  its  counterpart. 
What  has  been  said  about  mania  is  applicable  to  the 
periodic  depression. 

Normal Normal Normal  Normal 

siate       V  /btute  \  /  state  \  /    State 

Depression  Depression  Depression 

SCHEME  II.     RECURRENT  MELANCHOLIA 

(B)  Alternating  insanity. — The  attacks  of  mania  and 
those  of  depression  alternate  and  are  separated  from 
each  other  by  normal  intervals. 

Excitement  Excitement 

Depression  Depression 

SCHEME  III.     ALTERNATING  INSANITY. 

Insanity  of  double  form. — Each  attack  consists  of  a 
period  of  depression  and  one  of  excitement ;  the  attacks 
are  separated  from  each  other  by  normal  intervals. 

Excitement  Excitement  Excitement 

Normal / \  Normal / \  Normal         / \  Normal 

State  \      j  State  \      ~f  StateT     ~t  State 

Depression.  Depression  Depression 

SCHEME  IV.     INSANITY  OF  DOUBLE  FORM. 

(C)  Circular  insanity. — Attacks  of  double  form  follow 
each  other  without  interruption. 

Excitement  Excitement  Excitement 


Normal  / \  Normal  Normal  / \  Normal  formal 

State  State  \  /State  State  \  /  State       ' 


Depression  Depression  Depression  Depression 

SCHEME  V.     CIRCULAR  INSANJTY. 


2SG  MANUAL  OF  PSYCHIATRY. 

(D)  Irregular  forms. — These  are  the  most  frequent. 
The  attacks  follow  each  other  without  order  or  regu- 
larity, assuming  at  random  the  depressed,  manic,  or 
mixed  form. 

Finally,  one  may  observe  the  periodic,  circular,  and 
atypical  forms  combine  themselves  in  a  very  complex 
manner,  so  that,  for  instance,  a  patient  with  circular 
insanity  becomes  a  periodic  maniac  for  a  time,  or  a 
patient  whose  previous  attacks  have  all  been  of  the 
manic  type  presents  an  attack  of  depression. 

It  is  quite  frequent,  though  not  constant,  to  see 
attacks  of  the  same  type  present  each  time  the  same 
aspect:  a  manic  attack  resembles  previous  ones  in  the 
same  patient,  and  it  is  very  probable  that  the  future 
manic  attacks  will  present  the  same  features. 

The  general  prognosis  of  the  disease  is  not  favorable. 
The  attacks  have  in  the  majority  of  cases  a  tendency 
to  occur  closer  together,  so  that  the  normal  intervals 
become  gradually  shorter  and  shorter  until  they  are 
either  totally  wanting  or  almost  so. 

Manic  depressive  insanity  is  a  frequent  disease. 
According  to  Kraepelin  it  represents  about  15%  of 
all  asylum  admissions. 

The  immediate  causes  are  unknown.  Those  to 
which  the  patients  or  their  relatives  attribute  the 
attacks  are  usually  unsubstantiated.  It  seems  to  be 
established  that  heredity  is  very  frequent.  Kraepelin 
has  found  it  in  80%  of  the  cases.  It  is  often  similar. 
One  point  is  certain:  manic  depressive  insanity  is  a 
disease  of  the  degenerate.  Vague  as  this  conception 
of  the  etiology  is,  we  must  be  content  with  it  for  the 
present  for  want  of  a  better  one. 


MANIC  DEPRESSIVE   INSANITY.  287 

The  age  at  which  the  first  attack  occurs  is  not  constant. 
In  most  cases  it  is  before  the  twenty-fifth  year,  in 
some  before  the  tenth,  and  in  others  after  the  fiftieth. 
Quite  frequently  in  women  the  disease  appears  with 
the  onset  of  menstruation  or  with  the  first  pregnancy. 

Diagnosis. — The  principal  elements  of  diagnosis  are 
the  psychic  paralysis  associated  with  the  special  symp- 
toms of  exaltation  of  the  mental  automatism,  which 
have  already  been  described;  the  absence  of  real  intel- 
lectual enf eeblement ;  the  recurrence  of  the  attacks 
with  restitutio  ad  integrum  after  each. 

We  differentiate : 

General  paresis  by  the  pathognomonic  intellectual 
enfeeblement,  a  certain  degree  of  which  persists  even 
during  the  remissions;  and  by  the  equally  pathogno- 
monic physical  signs; 

Involution  melancholia  by  the  intense  and  persistent 
moral  pain,  which  is  much  more  marked  than  in  the 
depressed  form  of  manic  depressive  insanity; 

Acute  confusional  insanity  by  its  special  etiology, 
and  by  the  much  more  marked  disorientation; 

Delirium  tremens  by  its  specific  hallucinations; 

Dementia  prcecox  by  the  rapid  and  pronounced 
diminution  of  the  affectivity,  by  the  catatonic  phenom- 
ena which  are  so  frequent  in  such  cases,  and  by  the 
absence  of  flight  of  ideas  even  in  those  cases  which 
closely  resemble  mania. 

Homogeneity  of  manic  depressive  insanity.  Funda- 
mental symptoms.— The  conception  of  manic  depressive 
insanity  is  due  to  Kraepelin  and  constitutes  one  of 
the  most  important  recent  advances  in  psychiatry. 
Although   the   grouping  of  such   apparently   different 


288  MANUAL  OF  PSYCHIATRY. 

and  even  opposite  pathological  states  as  melancholic 
depression  and  mania  may  appear  unreasonable  on 
superficial  consideration,  its  legitimacy  is  nevertheless  in- 
contestable and  is  based  upon  two  principal  arguments : 

(1)  The  existence  of  fundamental  symptoms  common 
to  all  forms,  manic,  depressed,  or  mixed; 

(2)  The  alternation,  regular  or  not,  as  the  case  may 
be,  of  the  phenomena  of  excitement  and  of  depression 
in  the  same  subject. 

(1)  Fundamental  symptoms. — The  symptoms  described 
above  can  be  readily  divided  into  two  groups: 

The  first  group  comprises  all  the  morbid  phenomena 
dependent  upon  psychic  paralysis,  namely:  (a)  En- 
feeblement  of  the  attention;  (b)  sluggishness  of  the 
associations  of  ideas;  (c)  insufficiency  of  perception; 
(d)  pathological  indifference. 

These  symptoms  are  constant  and  are  encountered 
in  the  manic  as  well  as  in  the  depressed  forms,  though 
they  are  usually  more  apparent  in  the  latter.  We  have 
already  seen  that  the  mobility  of  the  attention  which 
results  from  an  impairment  of  that  function  is  one  of 
the  fundamental  signs  of  mania.  We  also  know  that 
Kraepelin  has  shown  by  psychometric  experiments 
that  there  is  an  unmistakable  sluggishness  of  the 
associations  of  ideas  in  mania.  These  two  symptoms 
determine  a  diminution  of  the  capacity  for  intellectual 
labor,  which  diminution  exists  both  in  the  depressed 
and  in  the  manic  forms.  Again,  perceptions  of  the 
external  world  are  disordered  alike  in  both  forms,  the 
depressed  and  the  manic.  But  while  in  the  former 
the  impressions  are  often  incomplete  and  are  clinic- 
ally expressed  by  uncertainty;  in  the  latter  automatic 


MANIC  DEPRESSIVE  INSANITY.  289 

associations  take  the  p'ace  of  the  normal  ones,  which 
are  wanting,  giving  rise  to  false  perceptions,  illusions. 
Neither  the  maniac  nor  the  melancholiac  perceives  the 
phenomena  of  the  external  world  in  their  true  aspect, 
but  the  latter  remains  in  doubt,  while  the  former  affirms 
errors.  As  to  the  morbid  indifference,  it  is  also  present 
in  both  conditions;  to  be  convinced  of  this  it  is  sufficient 
to  recall  the  perfect  serenity  with  which  the  maniac 
receives  the  news  of  a  misfortune  in  his  family  which, 
in  the  normal  state,  would  profoundly  depress  him. 

The  psychic  inhibition  expressed  by  these  four 
symptoms  is,  therefore,  the  fundamental  and  constant 
disorder  which  is  the  common  basis  of  the  diverse  clin- 
ical types  of  attacks  of  manic  depressive  insanity. 

The  symptoms  of  the  second  group  are  dependent, 
not  upon  psychic  inhibition,  but  upon  exaltation  of  the 
mental  automatism,  which  so  often  accompanies  it. 
The  principal  symptoms  of  this  group  are:  (a)  Flight 
of  ideas;  (6)  irritability;  (c)  impulsive  actions;  (d)  delu- 
sions and  psycho-sensory  disorders;  (e)  fixed  ideas  and, 
occasionally,  obsessions. 

All  these  morbid  phenomena  are  incidental.  Their 
presence  or  absence  modifies  the  aspect  but  not  the 
nature  of  the  attack.  Some  appear  with  equal  fre- 
quency in  mania  and  in  melancholia;  such  are  the 
delusions  and  hallucinations.  Others  are,  on  the 
contrary,  peculiar  to  one  or  the  other  of  the  morbid 
types :  flight  of  ideas,  irritability,  impulsiveness  in 
mania,  fixed  ideas  in  melancholia.  But  there  is  no 
absolute  rule  in  this  respect;  we  meet  with  depressed 
cases  with  flight  of  ideas,  and  with  maniacs  whose 
delusions  are  more  or  less  fixed. 


290  MANUAL  OF  PSYCHIATRY. 

(2)  Alternation  of  excitement  and  depression  in  the  same 
subject. — The  close  relationship  existing  between  states 
of  depression  and  maniacal  states  becomes  still  more 
evident  when;  instead  of  considering  a  single  attack, 
we  make  a  study  of  all  the  attacks  in  the  same  indi- 
vidual. First  of  all,  it  is  extremely  rare  for  a  patient 
to  have  only  one  attack  of  mania  or  of  melancholic 
depression  in  his  life.  Thus  isolated  and  non-recurring 
mania  or  melancholic  depression  is  almost  eliminated. 
In  some  cases,  it  is  true,  the  attacks  are  always  manic, 
while  in  some  others  they  are  always  depressed.  These 
two  groups,  apparently  separated  by  an  unfathomable 
abyss,  are  in  reality  connected  by  a  much  larger  group 
of  double,  alternating,  circular,  and  irregular  forms, 
which  establish  an  insensible  transition  from  one  to 
the  other.  Moreover,  a  close  study  of  cases  shows  that 
the  majority  of  attacks  presenting  the  manic  type  or 
the  depressed  type  are  in  reality  attacks  of  double 
form.  In  fact,  on  careful  inquiry  we  find  that  almost 
constantly  the  maniacal  symptoms  are  preceded  by  a 
prodromal  period  characterized  by  more  or  less  marked 
depression;  again,  we  often  observe  an  attack  of  depres- 
sion to  be  followed  by  a  state  of  excitement  which  can- 
not be  attributed  to  any  known  cause,  not  even  to  the 
patient's  prospect  of  returning  to  his  usual  mode  of 
life  in  the  near  future.  Thus  all  attacks  of  mania 
and  of  melancholic  depression  contain  in  a  rudimentary 
form  the  elements  of  excitement  and  of  depression. 
Circular  insanity  thus  becomes  the  prototype  from  which 
the  other  forms  are  derived. 

The  above  considerations  show  us  that,  in  spite  of 
the  apparent  diversity  of  the  symptoms;  mania,  melan- 


MANIC  DEPRESSIVE  INSANITY.  291 

cholic  depression,  and  their  various  combinations  are 
not  to  be  considered,  as  heretofore,  as  different  morbid 
entities,  and  that  the  following  conclusion  arrived  at 
by  Kraepelin  is  perfectly  justifiable: 

"The  diverse  forms  which  have  been  described  are 
but  different  manifestations  of  one  and  the  same  funda- 
mental pathological  process,  equivalents,  like  the  many 
forms  assumed  by  epileptic  paroxysms. "  * 

[Treatment. — For  the  treatment  of  the  symptoms 
which  may  arise  in.  the  different  forms  of  manic  de- 
pressive insanity  the  reader  is  referred  to  the  general 
discussion  on  the  treatment  of  insanity  in  the  first  part 
of  this  book.  As  to  the  question  of  prevention  of 
recurrency  the  most  important  point  to  bear  in  mind  is 
the  necessity  of  insisting  upon  the  absolute  suppression 
of  all  forms  of  alcoholic  beverages.  A  single  drink  of 
whiskey  has  been  known  to  act  as  the  undoubted  cause 
of  an  attack  in  a  manic  depressive  individual,  and  there 
are  some  cases  in  which  most  of  the  attacks  are  attrib- 
utable to  overindulgence  in  alcohol. 

An  attempt  has  been  made  by  Kohn  to  prevent  the 
recurrence  of  attacks  in  cases  in  which  the  outbreaks 
are  brief  and  frequent  and  occur  with  such  regularity 
that  the  date  of  their  onset  can  be  predicted  with  more 
or  less  accuracy.  In  such  cases,  beginning  several 
days  before  the  expected  attack,  the  patient  is  given 
from  12  to  15  grams  of  potassium  bromide  daily  until 
the  " danger  period"  is  over,  when  the  dose  is  gradually 
diminished  and  the  drug  finally  discontinued.  It  seems 
possible  to  prevent  the  outbreaks  of  excitement  by 
this  method  of  treatment.] 

1  Kraepelin.     Lehrbuch  der  Psychiatrie,  Vol.  II,  p.   558. 


CHAPTER  XIII. 
REASONING  INSANITY1 

(kraepelin's  paranoia). 

Reasoning  insanity  is  to  be  looked  upon  as  the  devel- 
opment of  a  morbid  germ  the  existence  of  which  mani- 
fests itself  in  early  life  by  anomalies  of  character. 
These  anomalies  may  be,  to  use  the  apt  expression  of 
Seglas,  ' *  summarized  in  two  words :  arrogance  and  mis- 
trust. "  At  a  certain  time  the  pathological  tendencies  of 
the  subject  find  their  expression  in  a  fixed  idea,  and 
the  delirium  is  established. 

Onset. — Sometimes  it  is  slow  and  gradual,  much  more 
frequently  rapid,  almost  sudden. 

In  the  first  case  the  dominant  traits  of  the  personality 
become  accentuated  little  by  little.  The  individual 
grows  more  and  more  suspicious  and  vain  and  believes 
himself  to  be  the  object  of  malevolent  or,  on  the  con- 
trary, admiring  reflections  by  some  people  or  other. 
Dek-sional  interpretations  become  more  and  more 
numerous  until  finally  the  -fixed  idea  appears,  an  idea  of 
persecution  or  of  grandeur,  around  which  a  whole  delu- 
sional system  is  subsequently  built  up. 

1  Leroy.  Les  persecutes  persccuteurs.  These  de  Paris,  1896. — 
Ballet  et  Roubinowitch.  Les  persecutes  persccuteurs. — Magnan. 
Lecons  cliniques. 

292 


REASONING  INSANITY.  293 

In  the  second  case  the  fixed  idea  is  primary  to  the 
delusional  interpretations.  Sometimes  it  appears  in 
childhood,  as  in  a  case  of  Mangan's:  the  boy  when 
questioned  concerning  his  vocation  replied  that  he  was 
going  to  become  a  pope.  Sander  has  described  this 
form  under  the  name  "paranoia  originaire." 

Usually  the  fixed  idea  appears  at  a  later  period,  in 
youth  or  in  adult  age.  Often  it  is  based  upon  some 
real  fact  the  significance  of  which  the  patient  misin- 
terprets or  the  importance  of  which  he  exaggerates: 
perfectly  justifiable  disciplinary  measures  of  which  he 
is  the  object,  loss  of  money,  or  sometimes  indeed  a  true 
injustice,  against  which,  however,  nothing  can  be  done, 
may  determine  the  onset  of  the  disease.  Often,  also,  it 
has  for  its  basis  the  extreme  credulity  of  the  patient,  who 
takes  in  earnest  a  simple  pleasantry  or  some  silly  remark. 
"He  resembles  Napoleon,"  was  once  remarked  by 
some  one  in  the  presence  of  a  psychopath.  Immediately 
the  latter  conceived  the  idea  that  he  belonged  to  the 
royal  family  and  that  he  was  "the  master  of  France," 
and  this  formed  the  starting-point  of  his  system  of  de- 
lusions. 

Fundamental  character  of  the  delirium. — As  soon  as 
the  theme,  that  is  to  say  the  fixed  idea,  is  formed, 
the  disease  develops  very  rapidly  and  is  characterized 
by: 

(1)  The  immutability  of  the  fundamental  fixed  idea; 

(2)  The  absolute  faith  which  the  patient  has  in  his 
delusions; 

(3)  The  apparent  logic  of  the  delusional  system; 

(4)  The  promptness  and  intensity  of  the  reactions; 

(5)  The  absence  or  at  least  extreme  rarity  of  hallu- 


294  MANUAL  OF  PSYCHIATRY 

cinations  and  the  presence  of  numerous  false  interpreta- 
tions; 

(6)  The  absence  of  intellectual  enfeeblement  regard- 
less of  the  length  of  time  that  the  disease  has  lasted. 

The  following  brief  abstract  from  an  observation 
upon  a  case  illustrates  these  characteristics  in  a  some- 
what schematic  fashion. 

A  schoolmaster,  who  was  a  man  of  average  intelligence, 
but  suspicious  and  conceited,  failed  to  receive  a  promo- 
tion which  he  believed  he  had  a  right  to  expect.  The 
idea  that  he  was  the  victim  of  a  grave  injustice  arose  in 
his  mind  and  never  left  it  (immutability  of  the  fixed  idea). 
The  reasonings  of  his  friends  and  relatives  could  not 
alter  his  conviction  and  failed  to  persuade  him  from 
addressing  a  letter  of  strong  protestation  to  the  school 
director  (absolute  faith  in  his  delusions,  promptness  and 
intensity  of  the  reactions).  This  producing  no  effect 
aside  from  the  loss  of  his  position,  he  applied  to  the 
minister  of  public  instruction,  to  the  president  of  the 
republic,  to  the  tribunals.  He  found  no  justice,  but 
nevertheless  retained  confidence  in  the  excellence  of 
his  cause,  attributing  his  successive  disappointments  to 
the  dishonesty  of  the  representatives  of  authority  and 
justice,  who  he  claimed  were  in  league  against  him 
because  his  high  intellect  overshadowed  them.  Every- 
thing now  became  clear  to  him;  he  understood  the 
distrust  shown  towards  him  and  the  attention  which  he 
attracted  wherever  he  went  (apparent  logic  of  the  delu- 
sions, false  interpretations).  Finally  committed,  he 
continued  to  protest  against  his  persecutors,  among 
whom  were  included,  as  might  be  expected,  the  physician 
who  treated  him  and  the  police  officer  who  arrested 


REASONING  INSANITY.  295 

him;  the  memory  still  remains  perfect  and  the  mind 
lucid,  although  the  disease  has  now  lasted  over  25  years 
(absence  of  intellectual  enfeeblement). 

It  is  often  stated  that  the  delusions  of  paranoiacs 
are,  in  a  manner,  logical;  that  is  to  say,  when  the  fixed 
idea  once  appears  the  secondary  delusional  conceptions 
are  the  natural  outcome.  Thus  presented  this  state- 
ment is  not  correct.  In  fact,  if  these  patients  pos- 
sessed a  faultless  logic  it  would  render  apparent  to 
them  the  inconsistency  of  their  fixed  idea,  which  would 
be  immediately  abolished.  It  is  quite  true  that  these 
patients  are  very  apt  to  use  and  abuse  deductions  and 
syllogisms,  which  trait  has  given  them  the  name  of 
the  reasoning  insane.  But  their  logic  is  only  apparent; 
their  reasoning  is  always  tainted  with  the  same  original 
vice  that  leads  them  to  the  systematic  rejection  of 
arguments  opposing  their  ideas,  and  the  ready  accep- 
tance as  reality  of  hypotheses  which  arise  in  their 
minds  as  a  result  of  their  pathological  preoccupations. 
Hence  their  delusional  interpretations,  which  become 
more  numerous  each  day  and  upon  which  they  base 
their  arguments,  and  the  childish  character  of  the 
proofs  which  they  accumulate.  A  vague  word  or  an 
evasive  reply  often  suffices  to  convince  them  that 
their  standpoint  of  view  has  been  adopted  and  that 
their  cause  has  been  accepted.  The  concessions  occa- 
sionally made  by  those  against  whom  their  delusions 
are  directed,  become,  in  their  eyes,  ample  proof  that 
these  people  admit  their  guilt;  thus  misinterpreted 
chance  occurrences  serve  to  feed  the  delirium. 

Quite  frequently  their  reasoning,  subtle  and  plausible, 
though   radically   false,    is   imposed   upon   suggestible 


296  MANUAL  OF  PSYCHIATRY. 

individual  or  upon  those  of  shallow  minds.  Thus 
they  often  have  defenders  who  show  more  zeal  than 
intelligence.  The  history  of  the  famous  Sandon  presents 
such  an  example. 

Forms. — "  According  to  their  specific  morbid  ten- 
dencies paranoiacs  may  be  classed  in  different  groups: 
the  litigious  paranoiacs  (paranoia  querulens  of  the 
Germans) ,  who  prosecute  their  imaginary  rights  in 
the  courts;  the  hypochondriacal  paranoiacs,  who,  believ- 
ing themselves  to  have  been  once  improperly  treated  by 
a  physician,  bear  a  grudge  against  all  physicians  whom 
they  may  meet  in  the  course  of  their  treatment,  and 
annoy  them  in  various  ways;  the  filial  paranoiacs, 
who  believe  that  they  have  found  their  father  in  some 
stranger,  whom  they  constantly  annoy  with  their 
expressions  of  tenderness  and  with  their  claims. 
Another  group  is  formed  by  the  amorous  paranoiacs: 

Teulat,  the  lover  of  Princess  de  B ,  was  a  splendid 

example  of  this  type"  (Magnan). 

To  the  preceding  groups  should  be  added  the  jealous 
paranoiacs,  in  whom  the  delusions  assume  the  form  of 
morbid  jealousy;  inventors  who  are  indignant  for  the 
rejection  of  their  fantastic  inventions;  mystics  and 
founders  of  religions  who  often  succeed  in  gathering 
beneath  their  banners  an  imposing  train  of  feeble- 
minded, or  at  least  unbalanced,  individuals,  etc. 

The  list  might  be  prolonged  indefinitely;  it  is  useless, 
however,  for  whatever  be  the  nature  of  the  fixed  idea, 
the  clinical  characteristics  of  the  delirium  do  not  vary. 

Diagnosis. — The  first  question  that  may  arise  in  the 
mind  of  the  physician  is,  Are  the  ideas  of  the  subject 
delusional  or  not?    It  is  not  always  easy  to  answer 


REASONING  INSANITY.  297 

this  question.  Delusions  sometimes  appear  very  prob- 
able, while,  on  the  other  hand,  well-based  claims  may 
resemble  the  delusions  of  reasoning  insanity  on  account 
of  the  obstinacy  with  which  they  are  urged.  Only 
by  a  very  careful  examination  of  each  case  can  errors 
be  avoided. 

The  diagnosis  is  to  be  based  upon  the  fundamental 
characters  enumerated  above;  all  these  characters 
together  are  not  observed  in  any  other  psychosis. 

In  favor  of  paranoid  dementia  are  intellectual  enfeeble- 
ment  and  the  more  mobile  character  of  the  delusions. 
In  chronic  delirium  there  is  the  constant  presence 
of  hallucinations  and  a  progressive  evolution  of  the 
disease.  In  the  jealous  delirium  of  alcoholism  we  find 
a  less  perfect  systematization  of  the  morbid  ideas, 
the  constant  presence  of  hallucinations,  the  alcoholic 
stigmata,  and  the  tendency  towards  recovery. 

Prognosis  and  treatment. — Reasoning  insanity  is  a 
chronic,  incurable  affection  which,  as  we  have  seen, 
entails  no  intellectual  enfeeblement.  The  violence  of 
the  reactions  almost  always  renders  commitment 
necessary.  There  are  no  known  means  for  combating 
the  delusions.  Moral  treatment  has  no  influence  what- 
ever. 


CHAPTER  XIV. 

CONSTITUTIONAL   PSYCHOPATHS. 

SEXUAL  PERVERSION  AND  INVERSION.— OBSESSIONS. 

§  1.  Constitutional  Psychopaths. 

Among  degenerates  there  are  some  who  present  from 
their  childhood  evident  psychic  anomalies  which  justify 
their  being  classed  in  a  separate  group, — the  con- 
stitutional psychopaths. 

From  this  group  must  be  eliminated  epileptics, 
hysterical  subjects,  paranoiacs,  and  the  feeble-minded, 
which,  in  spite  of  their  close  relationship  to  the  psy- 
chopaths, really  form  independent  categories.  Such 
distinctions  are  necessary  for  the  avoidance  of  confu- 
sion in  the  theory  and  practice  of  psychiatry. 

We  shall  study  first  the  habitual  mental  state  of  the 
psychopaths,  then  the  anomalies  of  the  sexual  life, 
which,  on  account  of  their  importance,  merit  a  separate 
description,  and  finally  obsessions. 

§  2.  Habitual  Mental  State  of  Psychopaths. 

The  principal  anomalies  are  those  of  (a)  the  judg- 
ment, (b)  the  character,  and  (c)  the  conduct. 

(a)  Disorders  of  judgment. — These  constitute  perhaps 

the  most  essential  stigma  of  the  psychopath  as  well  as 

298 


CONSTITUTIONAL  PSYCHOPATHS.  299 

the  most  important  one  from  the  social  standpoint  of 
view.  The  psychopath  does  not  see  things  in  their  proper 
light,  hence  his  singular  notions,  his  paradoxes,  his  ridic- 
ulous enterprises. 

Usually  he  presents  a  more  or  less  pronounced  state 
of  mental  debility:  weakness  of  the  attention  or  of  the 
memory,  sluggishness  of  the  association  of  ideas,  and 
poverty  of  the  imagination.  In  some  cases,  however, 
some  of  the  faculties  are  normal  or  even  brilliant: 
memory,  imagination,  or  artistic  aptitudes.  But  these 
abilities  cannot  be  turned  to  account  by  reason  of 
the  lack  of  judgment,  for  almost  always,  if  he  is  not 
actually  feeble-minded,  he  is  at  least  mentally  unbal- 
anced. 

(6)  Anomalies  of  the  character. — These  are  very  varied. 

Sometimes  they  consist  in  a  general  pessimism:  the 
patient  sees  only  the  dark  side  of  life;  all  occurrences 
make  a  painful  impression  upon  his  mind. 

Usually  the  dominant  note  in  the  character  of  the 
psychopath  is  the  extreme  mobility  of  the  sentiments. 
The  subject  passes  alternately  from  exuberant  joy  to 
boundless  desolation,  from  feverish  activity  to  pro- 
found discouragement,  from  affection  to  hatred,  from 
the  most  complete  egoism  to  the  most  exaggerated 
generosity  and  devotion.  Thus  the  name  unbalanced 
is  perfectly  applicable  to  this  class  of  patients. 

(c)  The  conduct  shows  the  insufficiency  of  judgment 
and  the  instability  of  the  emotions.  It  is  full  of  con- 
tradictions. 

The  psychopath  is  apt  to  pose  as  a  champion  of 
justice,  as  an  avenger  of  humanity.  lie  is  given  to 
anarchistic  ideas,  seeks  to  interfere  in  public  affairs, 


300  MANUAL  OF  PSYCHIATRY. 

to  become  a  leader  of  popular  movements,  and  he 
succeeds  but  too  often.  His  conduct  is  often  incon- 
sistent with  his  ideas  of  justice  and  charity,  though 
he  fails  to  see  it  himself.  Theoretically  he  strives  for 
the  good  of  the  universe,  practically  for  the  satisfac- 
tion of  his  own  egoistic  tendencies. 

He  tries  all  sorts  of  occupations,  but  succeeds  in 
none,  and  accuses  his  fate  or  the  injustice  of  men.  He 
is  apt  to  pose  as  a  victim,  while  in  reality  he  is  what 
is  aptly  designated  by  the  popular  expression  "a,  ne'er- 
do-well."  If  he  has  no  personal  resources  and  if  he 
is  not  aided  by  his  relatives  or  by  public  charity  he 
becomes  a  vagabond. 

The  psychical  anomalies  are  almost  constantly  associ- 
ated with  the  physical  ones,  which  are  known  as  the 
physical  signs  of  degeneration.  Most  of  these  abnormal- 
ities may  be  encountered  in  normal  individuals.  Only 
the  combination  of  many  of  them  in  the  same  subject 
renders  them  of  importance;  they  are  more  numerous 
among  the  insane  than  among  normal  individuals ;  they 
are  also  more  numerous  in  constitutional  psychopaths, 
epileptics,  and  hysterical  individuals  than  they  are 
in  other  degenerates.  They  possess  a  great  theoretical 
interest  because  they  are,  so  to  speak,  the  stamp  of 
degeneration,  and  are  a  proof  of  the  fact  that  the  mor- 
bid process  affects  the  entire  organism.  On  the  other 
hand,  they  are  not  of  very  great  practical  interest; 
therefore  I  shall  limit  myself  to  the  mere  mention  of 
the  principal  ones. 

Cranial  malformations:  macrocephaly,  microcephaly, 
scaphocephaly ,  extreme  brachycephaly  or  dolichocephaty, 
etc.;  cranio-facial   asymmetry,  harelip,   malformations 


CONSTITUTIONAL   PSYCHOPATHS.  301 

of  the  palate;  dental  anomalies:  congenital  absence 
of  one  or  several  teeth,  irregularities  of  implantation, 
malformations  (Hutchinson's  teeth);  anomalies  of  the 
auricle:  defective  lobule,  abnormal  development  of 
the  Darwinian  tubercle,  absence  of  the  helix;  irregular 
pigmentation  of  the  irides,  strabismus;  malformations 
of  the  external  genital  organs:  cryptorchydism,  infan- 
tilism, hypo-  or  epispadias,  pseudo-hemaphroclitism; 
anomalies  of  the  length  of  the  limbs:  oligodactylism,  etc. 

Together  with  the  anatomical  anomalies  should  be 
ranged  the  numerous  tattooings  with  which  many  psy- 
chopaths are  covered,  and  which  usually  indicate  a 
morbid  mental  state. 

Tattoo-marks,  so  frequently  observed  among  the 
insane  and  among  criminals,  are  a  sort  of  acquired  sign 
of  degeneration.1 

§  3.  Anomalies  of  the  Sexual  Life. 

We  usually  distinguish: 

(A)  Anomalies  of  degree:    eroticism;    frigidity. 

(B)  Anomalies  of  nature:  sexual  perversion;  sexual 
inversion. 

(A)  Anomalies  of  degree. — Eroticism  results  in  vene- 
real excesses  and  often  in  indecent  acts  and  attempts 
at  rape. 

Sexual  frigidity  consists  in  an  indifference  and  even 
an  aversion  of  the  subject  to  sexual  connection;  at 
least  to  normal  sexual  connection,  for  frigidity  may 
be    associated    with    sexual    perversion    or    inversion. 

1  Martin.     Les  tatouages  chez  les  (Minis,     These  de  Paris,  1900, 


302  MANUAL  OF  PSYCHIATRY. 

A  curious  and  apparently  paradoxical  fact  is  its  fre- 
quency among  prostitutes. 

(B)  Anomalies  of  nature. — Sexual  perversion  consists 
in  the  abnormal  character  of  the  conditions  necessary 
to  excite  the  sexual  desire  and  sometimes  its  gratifica- 
tion. Its  most  common  forms  are  masturbation, 
fetichism,  exhibitionism,  sadism,  and  masochism. 

Masturbation  is  very  frequent  in  psychopaths.  Often 
appearing  very  early,  it  is  to  be  regarded  as  a  sign 
and  not  as  a  cause  of  degeneration,  though  in  all  prob- 
ability it  accentuates  the  already  existing  defects. 

Fetichism,  occurring  almost  exclusively  in  men,  is 
an  anomaly  in  which  sexual  excitement  and  gratifica- 
tion are  produced  by  the  sight  or  contact  of  certain 
objects,  or  of  certain  parts  of  the  female  body  other 
than  the  genital  organs. 

Fetiches  may  be  (a)  various  objects:  articles  of 
clothing  (gowns,  petticoats,  handkerchiefs),  toilet  arti- 
cles, laces,  expensive  fabrics,  in  a  word,  all  objects 
used  by  women;  (6)  parts  of  the  body:  the  breasts, 
the  hands,  the  feet,  the  hair.  Several  fetiches  may 
be  associated  in  the  mind  of  the  same  patient. 

Moll  has  justly  remarked  that  the  mere  fact  that 
an  individual  has  a  predilection  for  some  portion  of 
the  female  body  does  not  in  itself  constitute  fetichism. 
uOne  may  like  by  preference  a  pretty  mouth,  light 
or  dark  hair,  or  large  eyes,  without  having  any  genital 
perversion. "  Similarly  a  letter  or  an  object  belonging 
to  a  woman  may  produce  an  agreeable  impression  by 
the  recollections  which  it  gives  rise  to.  An  anomaly 
is  present  only  when  the  presence  or  mental  representa- 
tion of  such  objects  is  in  itself  efficient  and  provokes 


CONSTITUTIONAL   PSYCHOPATHS.  303 

sexual  excitement  without  giving  rise  to  any  recollection 
of  some  particular  woman. 

Fetichism  often  appears  at  the  same  time  when  the 
sexual  instinct  becomes  manifest.  The  choice  of  the 
fetich  depends  upon  the  impression  which  is  accidentally 
associated  with  the  first  genital  excitement.  While 
in  the  normal  individual  this  accidental  association 
leaves  no  trace,  in  the  fetichist  the  impression  and 
the  excitation  form  an  indissoluble  combination,  so 
that  the  first  invariably  brings  about  the  second. 

The  desire  to  possess  the  fetich  is  sometimes  so 
intense  as  to  lead  the  patient  to  thefts  or  to  various 
peculiar  acts.  One  patient  of  Vallon's  was  arrested 
while  cutting  bits  of  cloth  from  the  dresses  of  women 
who  were  with  him  at  the  time  in  a  newspaper  office. 
Most  of  the  so-called  "  hair  despoilers  "  are  hair  fetichists. 

Exhibitionism  has  already  been  defined.  It  may  be 
met  with  in  dements  and  in  epileptics,  and  often  takes 
the  form  of  an  impulsive  obsession. 

Sadism  consists  in  a  sense  of  voluptuousness  derived 
from  suffering  which  the  patient  witnesses  in  or  inflicts 
upon  his  victim.  This  sense  is  almost  always  associated 
with  a  state  of  genital  excitation.  As  is  the  case  with 
most  sexual  anomalies,  it  is  more  frequent  in  men. 

History  contains  terrible  examples  of  sadism.  Such 
is  that  of  Marshal  Gilles  de  Rays,  who,  during  a  period 
of  eight  years,  assassinated  over  eight  hundred  children,1 
subjecting  them  previous^  to  defilement  and  torture. 
The  exploits  of  the  too-well-known  Vacher  are  still  fresh 
in  the  memories  of  most  of  us. 

1  Quoted  by  Krafft-Ebing  from  Jacob,  the  historian. 


304  MANUAL  OF  PSYCHIATRY. 

Sadism  is  exercised  chiefly  upon  women  and  upon 
children;    more  rarely  upon  animals. 

Many  sadists  content  themselves  with  simulation  of 
suffering  or  with  fictitious  humiliation  inflicted  upon 
their  pseudo-victim.  The  sadism  is  then  symbolic 
(Krafft-Ebing). 

Masochism,  unlike  sadism,  is  more  frequent  in  women. 
It  consists  in  an  abnormal  pleasure  which  the  subject 
derives  from  her  own  suffering  or  humiliation.  To 
this  category  belong  the  individuals  who  request  women 
to  strike  and  insult  them  and  in  whom  sexual  excitation 
cannot  be  produced  otherwise. 

Sexual  inversion  consists  in  the  contrast  existing 
between  the  physical  sex  and  the  psychical  sex:  the 
subject  presents  the  sexual  tendencies  of  the  opposite 
sex. 

Much  more  frequent  in  men  than  in  women,  sexual 
inversion  often,  but  not  always,  leads  to  pederasty. 
Sexual  inversion  is  always  congenital.  The  anomaly 
is  stamped  upon  the  entire  psychical  and  even  physical 
personality  of  the  subject. 

Many  of  these  individuals  have  •  the  character  and 
tastes  of  the  opposite  sex.  The  little  boy  plays  with 
dolls,  and  finds  pleasure  only  in  the  society  of  girls. 
Later  on  the  same  feminine  tendencies  persist,  and 
the  patient  secretly  abandons  himself  to  them.  We 
also  often  meet  with  men,  apparently  normal,  who 
in  their  privacy  dress  themselves  in  female  attire, 
cover  themselves  with  laces,  or  passionately  indulge 
in  feminine  employments,  as  sewing,  embroidery,  etc. 

Physically  certain  anomalies  are  noted  which  resemble 
the  normal  characteristics  of  the  feminine  organism: 


CONSTITUTIONAL  PSYCHOPATHS.  305 

considerable  development  of  the  breasts  and  hips, 
absence  of  the  beard,  rounded  shape  of  the  neck,  etc. 
Occasionally  we  observe  a  more  or  less  marked  degree 
of  pseudo-hermaphroditism. 

The  opposite  anomalies  are  encountered  in  the 
female  sexual  invert. 

Some  inverts  may  have  normal  sexual  intercourse, 
but  they  derive  no  satisfaction  from  it,  and  always  feel 
an  attraction  for  the  homologous  sex ;  often  they  marry, 
hoping  thus  to  cure  their  infirmity,  but  their  attempt 
is  never  successful. 

§  4.  Obsessions.1 

An  obsession  is  constituted  by  an  imperative  idea 
associated  with  a  state  of  anxiety,  there  being  no  marked 
disorder  of  the  consciousness  or  judgment. 

We  have  already  studied  imperative  ideas  and  learned 
that  they  constitute  a  form  of  mental  automatism. 

We  have  also  studied  the  principal  characteristics  of 
anxiety.  Its  relations  to  imperative  ideas  have  been 
much  discussed.  Westphal,  who  was  one  of  the  first 
to  make  a  thorough  study  of  obsessions,  is  of  the  opinion 
that  the  anxiety  is  always  secondary  to  the  imperative 
idea.  This  opinion  is  certainly  too  absolute,  for  the 
anxiety  may  precede  the  imperative  idea  and  even 
appear  independently  of  it. 

This  question  seems  to  be  analogous  to  that  which  we 
have  considered  in  connection  with  allopsychic  disorien- 

1  Arnaud.  Sur  la  theorie  de  V obsession.  Arch,  de  neurol.,  1902, 
No.  76. — Roubinowitch.  Etude  clinique  des  obsessions  et  des  im- 
pulsions morbides.  Ann.  med.  psych.,  Sept -Oct.  1899. — P.  Janet. 
Les  obsessions  et  Vanasthenie,  1902,  Paris,  F.   Alcan. 


306  MANUAL  OF  PSYCHIATRY. 

tat  ion  and  hallucinations.  I  am  inclined  in  this  case  to 
view  with  favor  a  similar  solution,  namely,  that  impera- 
tive ideas  and  anxiety  are  two  manifestations  of  the 
same  fundamental  psychical  disorder. 

Intact  consciousness  and  judgment  are,  as  we  have 
just  pointed  out,  the  rule  in  obsessions;  the  patient  is 
therefore  able  to  realize  the  pathological  nature  of  the 
phenomenon.  There  are,  however,  some  exceptions  to 
this.  The  subject  has  sometimes,  when  anxiety  appears 
in  the  paroxysm,  a  sense  of  a  reduplication  or  of  a 
transformation  of  the  personality.  One  such  patient  of 
Seglas  entered  a  shop  "to  speak  to  the  clerks,  to  ask 
for  something,  and  thus  to  find  new  proof  that  she  was 
her  real  self. " 

Obsessions  are  occasionally  accompanied  by  halluci- 
nations, chiefly  motor  hallucinations,  which  in  a  manner 
exteriorize  the  imperative  idea. 

Obsessions  are  of  various  forms.  First  of  all,  three 
great  classes  are  to  be  distinguished,  depending  upon 
the  influence  which  the  imperative  idea  exercises  upon 
the  patient:  (1)  intellectual  obsessions  which  are 
unaccompanied  by  any  voluntary  activity;  (2)  impul- 
sive obsessions,  in  which  the  idea  tends  to  be  trans- 
formed into  an  act;  (3)  inhibiting  obsessions  the 
action  of  which  tends  to  paralyze  certain  voluntary  acts. 

(1)  Intellectual  obsessions. — The  consciousness  of  the 
patient  is  occupied  either  by  some  concrete  idea, — a 
word,  an  object,  an  image  of  some  person  or  of  some 
scene, — or  by  some  abstract  idea,  often  of  a  metaphysical 
nature.  To  the  latter  category  belong  the  obsessions 
in  which  the  subject  has  a  feeling  that  he  does  not  exist, 
that  the  external  world  is  formed  of  nothing  but  phan- 


CONSTITUTIONAL  PSYCHOPATHS.  307 

toms,  etc.  The  imperative  idea  is  then  said  to  have  a 
negative  form.  In  other  instances,  without  going  so 
far  as  complete  negation,  it  is  expressed  by  doubt,  thus 
constituting  a  transitional  form  between  intellectual 
and  inhibiting  obsessions. 

(2)  Impulsive  obsessions. — These  are  very  numerous. 
The  following  are  the  principal  forms: 

Onomatomania:  an  irresistible  desire  to  pronounce 
certain  words,  sometimes  obscene  words  (coprolalia). 
Associated  with  a  tic,  coprolalia  constitutes  the  disease 
of  convulsive  tics  (the  disease  of  Gilles  de  la  Tourette). 

Arithmomania:  an  irresistible  desire  to  count  certain 
objects,  add  certain  figures,  etc. 

Kleptomania:  a  morbid  impulse  to  steal  objects  which 
are  entirely  useless,  or  which  the  subject  can  easily 
pay  for. 

Dipsomania:  an  irresistible  impulse  to  drink  alcoholic 
beverages  of  every  description  (wines,  liquors,  cologne- 
water,  spirits  of  camphor,  etc.),  occurring  in  a  person  of 
temperate  habits,  who  may  at  other  times  have  even 
an  actual  disgust  for  alcohol.  The  attacks  may  recur, 
and  the  dipsomaniac  may  become  an  alcoholic.  He 
differs  radically  from  the  ordinary  drunkard,  however. 
"The  one  is  alienated  before  beginning  to  drink,  the 
other  (the  alcoholic)  becomes  alienated  because  of  his 
drinking"  (Magnan). 

Pyromania. — Suicidal  and  homicidal  impidses.1 — These 
three  obsessions  are  of  equal  gravity  from  a  social  stand- 


1  Vallon.  Obsession  homicide.  Ann.  med  psych. ,  Jan.-Feb. 
1896. — Carrier.  Contribution  a  V etude  des  obsessions  et  des  impul- 
sions a  Vhomkide  et  au  suicide.     These  de  Paris,  1900. 


308  MANUAL  OF  PSYCHIATRY. 

point  of  view  and  may  be  placed  in  the  same  group. 
The  first  consists  in  a  morbid  impulse  to  set  buildings 
on  fire;   the  other  two  require  no  definition. 

In  some  cases  the  patients  obey  their  fatal  impulses. 
Yallon  has  reported  a  case  of  a  young  man  who,  having 
a  homicidal  obsession,  struggled  against  the  impulse, 
but  was  finally  overcome  and  yielded. 

Such  cases,  however,  are  rare.  Usually  the  patients 
succeed  by  various,  and  at  times  singular,  means  in 
resisting  their  impulse.  Many  take  flight  at  the  moment 
of  the  paroxysm;  others  request  to  be  restrained  or 
held;  still  others  voluntarily  have  themselves  com- 
mitted. One  patient  of  Joffroy's,  while  walking  in 
the  street,  was  seized  wTith  the  idea  of  throwing  her 
child  under  the  wheels  of  a  passing  car;  she  entered  a 
wine  merchant's  shop,  placed  her  child  upon  the  counter, 
and  took  flight. 

Similarly,  it  is  very  rare  for  patients  to  yield  to  a 
suicidal  impulse.  The  means  they  make  use  of  to 
escape  their  obsession  are  innumerable.  A  woman 
possessed  by  the  idea  of  throwing  herself  out  of  the 
window  had  all  the  windows  of  her  house  protected 
with  iron  bars.  Another  such  unfortunate  condemned 
herself  never  to  cross  the  Seine  River  to  prevent  herself 
from  obeying  the  impulse  which  she  had  to  drown 
herself  in  it. 

As  to  family  suicide,  it  is  almost  never  the  result  of 
an  obsession,  but  of  a  fixed  idea  which  is  developed 
from  example. 

(3)  Inhibiting  obsessions. — Like  the  preceding  ones, 
these  assume  very  varied  forms. 

One  of  the  most  frequent  is  the  "insanity  of  doubt." 


CONSTITUTIONAL  PSYCHOPATHS.  309 

Its  characteristic  feature  is  the  impossibility  of  the 
patient's  affirming  a  fact  or  of  making  a  determination. 

Many  normal  individuals  experience  this  phenomenon 
in  a  slight  degree.  At  the  borderland  of  the  insanity 
of  doubt  we  find  individuals  who  often  hesitate  several 
times  before  mailing  a  letter,  in  spite  of  having  already 
several  times  verified  the  contents,  the  address,  the 
sealing  of  the  envelope,  adherence  of  the  stamp,  etc. 

The  doubt  is  likely  to  assume  the  form  of  scruples, 
so  frequent  in  religious  persons:  a  fear  of  profaning 
sacred  objects,  of  not  being  in  a  holy  state  of  mind,  etc. 

Closely  related  to  the  insanity  of  doubt  are  the 
phobias,  which  are  usually  groundless  and  sometimes 
ridiculous;  their  absurdity  is  recognized  by  the  sub- 
ject himself. 

Some  patients  do  not  dare  to  touch  any  object,  con- 
stantly wear  gloves,  wash  their  hands  a  hundred  times 
daily,  etc.  This  phobia,  which  includes  also  the  fear 
of  contracting  an  infectious  disease  through  contact 
with  contaminated  articles  (nosophobia),  constitutes 
the  " delire  du  toucher." 

Others  have  a  fear  of  being  unable  to  stand  up  or 
to  accomplish  certain  movements,  such  as  walking. 
"'In  a  deserted  place,  in  a  very  wide  street,  upon  a 
bridge,  in  a  church,  or  in  a  theater  the  patient  sud- 
denly becomes  seized  with  the  idea  that  he  will  be 
unable  to  cross  the  wide  space  before  him,  that  he  is 
going  to  die,  or  that  he  is  going  to  be  sick."  1 

This  morbid  phenomenon,  known  as  agoraphobia, 
induces  a  veritable  functional  paralysis,  and  the  patient 

1  Regis.     Manuel  pratique  de  Medecine  mentale,  p.  279. 


310  MANUAL  OF  PSYCHIATRY. 

may  fall  if  he  is  not  supported.  The  slightest  support 
is  sufficient  to  calm  him  and  to  reassure  him;  the 
origin  of  the  attack  is,  therefore,  purely  psychical. 

Claustrophobia  is  the  opposite  of  agoraphobia;  it  con- 
sists in  the  impossibility  for  the  patient  to  remain  in 
a  closed  space. 

Erythrophobia,  first  described  by  Pitres  and  Regis, 
consist  in  a  fear  of  blushing.  These  patients  do  not 
dare  to  attract  anybody's  attention  to  themselves. 
This  phobia  is  closely  related  to  ordinary  timidity,  of 
which  it  is  occasionally  a  complication. 

Etiology. — The  etiology  of  obsessions  comprises  two 
principal  factors:  neuropathic  heredity  and  general 
enfeeblement  of  the  organism.  Thus  we  find  in  most 
of  the  victims  of  obsessions  a  more  or  less  charged 
heredity  associated  with  the  action  of  debilitating 
causes,  such  as  physical  and  intellectual  overwork,  preg- 
nancy, lactation,  abundant  and  repeated  hemorrhages. 

Obsessions  are  always  dependent  upon  a  pronounced 
neurasthenic  state;  thus  we  generally  distinguish 
obsessions  associated  with  congenital  neurasthenia, 
and  those  associated  with  acquired  neurasthenia, 
depending  upon  the  preponderance  of  neuropathic 
heredity  or  of  the  debilitating  causes  mentioned  above. 
This  distinction  is  an  artificial  one,  for  the  two  groups 
are  connected  by  an  infinite  number  of  intermediate 
forms. 

Treatment. — The  physical  treatment  consists  chiefly  in 
rest,  outdoor  life,  reconstructive  diet;  the  moral  treat- 
ment consists  in  hypnotic  or  simple  suggestion.  Simple 
suggestion  is  the  preferable  method  of  the  two,  as  these 
patients  usually  derive  little  benefit   from  hypnotism. 


CHAPTER  XV. 
EPILEPSY. 

From  a  psychiatrical  standpoint  of  view  epilepsy 
manifests  itself  by  permanent  disorders  and  by  par- 
oxysmal accidents. 

Permanent  intellectual  disorders. — These  impart  to 
the  epileptic  personality  a  peculiar  aspect  and  often 
lead  one  to  surmise  the  existence  of  the  neurosis  inde- 
pendently of  any  medical  examination.  We  shall 
consider  separately  the  peculiarities  of  the  epileptic 
character  and  those  of  the  intelligence. 

(A)  Peculiarities  of  the  character. — These  are  always 
very  marked.     The  following  are  the  principal  ones: 

(1)  Irritability  and  variability  of  moods,  egoism, 
duplicity. 

(2)  Habitual  apathy,  sudden  impulsive  reactions, 
violent  and  at  times  terrible  fits  of  anger. 

(3)  Lack  of  consistency  between  the  patient's  con- 
duct and  his  ideas,  more  rarely  abnormal  stubbornness 
and  tenacity :  ' '  Some  celebrated  men  who  are  supposed 
to  have  been  epileptics  are  more  noted  for  their  per- 
severance than  for  the  grandeur  of  their  conceptions.' '  1 

(4)  Morbid  religious   fanaticism,   not   constant,   but 


Fere.     Les  epilepsies  et  les  epileptiques,  p.  423. 

311 


312  MANUAL  OF  PSYCHIATRY. 

frequent,  usually  merely  ostentatious,  with  more  regard 
for  the  rites,  ceremonies,  and  customs,  and  without 
any  influence  upon  the  morality  of  the  patient. 

(B)  Disorders  of  intelligence. — Epileptics  are  some- 
times, but  not  often,  as  claimed  by  some  authors,  men 
of  great  intelligence.  Some  hold  prominent  places  in 
history,  in  literature,  and  in  the  arts:  such  were  Caesar, 
Napoleon,  Flaubert,  and  others.  Others,  though  in  a 
more  modest  sphere,  are  honorable  occupants  of  offices 
requiring  a  lucid  intelligence  and  a  sane  judgment. 
These  cases  are,  however,  exceptional.  Intellectual 
enfeeblement  almost  always  forms  a  part  of  the  clinical 
picture  of  epilepsy.  Often  it  is  congenital,  for  most  epi- 
leptics are  originally  feeble-minded;  in  other  cases  it  is 
acquired;  the  manifestations  of  epilepsy, — crises,  ver- 
tigo, delirium, — exercise  a  harmful  and  lasting  influ- 
ence upon  the  intelligence.  When  sufficiently  marked, 
the  intellectual  enfeeblement  becomes  epileptic  dementia. 

The  degree  of  dementia  depends  in  a  measure  upon 
the  number  and  the  severity  of  the  seizures.  "It  cannot 
be  doubted  that  the  stupor  produced  by  the  major 
attacks  is  more  marked  than  that  resulting  from  minor 
ones;  and  it  is  certain,  as  is  admitted  by  Legrand 
du  Saulle,  Voisin,  Sommer,  etc.,  that  major  seizures 
occurring  at  frequent  intervals  much  more  rapidly  lead 
to  dementia  than  do  the  incomplete  seizures/'  1 

The  two  essential  features  of  epileptic  dementia  are: 

(1)  Its  irregularly  progressive  development,  with  ag- 
gravations following  the  seizures;  (2)  its  being  to  a 
certain  extent  remittent,  the  intellectual  enfeeblement 

1  Fere.     hoc.  cit.,  p.  227. 


EPILEPSY.  313 

becoming  less  marked  as  the  intervals  between  attacks 
become  longer. 

Paroxysmal  mental  disorders. — These  are  either  asso- 
ciated with  or  replace  the  epileptic  seizures.  We  shall 
review  briefly  their  principal  forms. 

(A)  Sensory  and  psychical  auras. — The  first  consist 
in  hallucinations  or  illusions;  the  second  "  usually  con- 
sist in  a  recollection  of  either  an  agreeable  or  an  un- 
pleasant character:  perhaps  of  that  of  some  person  or 
of  some  important  event  in  the  patient's  life."  1 

(B)  Unconsciousness  accompaning  the  convulsive  phe- 
nomena: though  most  frequently  complete,  it  is  some- 
times but  partial,  giving  rise  to: 

(a)  Vertigo,  which  is  a  " dazzling  sensation"  rather 
than  true  vertigo,2  and  which  is  sometimes,  but  not 
always,  accompanied  by  falling  and  slight  convulsive 
movements.  Together  with  pallor  of  the  face  and  sub- 
sequent anaemia,  these  phenomena  constitute  a  rudi- 
mentary epileptic  seizure. 

(b)  Absence,  essentially  characterized  by  a  momentary 
suspension  of  all  psychic  operations.  The  patient  sud- 
denly becomes  immoblie,  his  gaze  fixed,  his  expression 
vacant;  the  attack  having  passed,  he  resumes  his  work 
or  conversation  at  the  point  where  he  left  off.  In 
some  cases  the  patient  continues  automatically  the 
work  or  the  movement  begun  before  the  attack.  A 
barber  mentioned  by  Besson  thus  continued  during  his 
absences  to  shave  his  clients,  performing  his  work  just 
as  skillfully  as  in  the  normal  state. 

Exceptionally  the  absence  is  prolonged  for  hours,  days, 

1  Magnan.     hoc.  cit.,  p.  6. 

2  Fere.     hoc.  cit.,  p.  136. 


314  MANUAL  OF  PSYCHIATRY. 

or  even  weeks.  Fere  rightly  includes  with  these 
absences  that  peculiar  variety  of  states  of  obscuration 
known  as  epileptic  automatism,  during  which  the  patient 
may  execute  complicated  acts,  such  as  taking  a'journey 
somewhere,  stopping  in  hotels,  etc.,  without  retaining 
any  recollection  of  them  after  the  attack.  Legrancle  du 
Salle  has  reported  a  curious  example  of  such  automatism: 
an  individual  who  was  at  Havre  when  his  attack  began, 
found  himself  on  the  way  to  Bombay  when  he  regained 
consciousness,  totally  ignorant  as  to  where  he  was  or 
how  he  came  there. 

These  states  resemble  the  states  of  somnambulism, 
with  which  they  may,  in  fact,  coexist. 

(C)  Stupor  following  the  seizures:  This  is  a  constant 
phenomenon  which  constitutes  in  doubtful  cases  an 
excellent  element  of  diagnosis  (Samt).  It  varies  in 
duration  from  several  minutes  to  as  many  hours. 

(D)  Delirium:  This  is  the  gravest  manifestation  of 
epilepsy.  Sometimes  it  accompanies  a  convulsive 
seizure;  at  other  times  it  precedes  or  follows  it;  still 
at  other  times  it  takes  the  place  of  a  seizure. 

It  begins  with  an  accentuation  of  the  disorders  of  the 
emotions  and  of  the  character.  The  patient  becomes 
irritable,  anxious,  and  the  delirium  establishes  itself 
very  rapidly,  often  within  several  minutes,  and  never 
taking  more  than  a  few  bours  for  its  development. 

The  fundamental  features  in  the  classical  form  are: 

(a)  Profound  clouding  of  consciousness,  with  complete 
disorientation  of  time  and  place ; 

(/?)  Anxiety  which  is  sometimes  terrible ;  in  some  cases 
it  gives  rise  to  violent  agitation; 

(j)  Numerous  hallucinations,  combined  so  as  to  con- 


EPILEPSY.  315 

stitute  complete  scenes,  associated  with  delusions  of  a 
painful  nature; 

(d)  Purely  automatic  and  extraordinarily  violent  re- 
actions; the  extreme  limit  of  this  violence  is  known  as 
the  epileptic  furor.  In  this  condition  the  patient  often 
commits  crimes  of  appalling  brutality  bearing  the  stamp 
of  absolute  unconsciousness.  He  kills  strangers  or  his 
own  children,  riddles  the  corpse  with  thrusts  of  his 
knife,  cuts  off  pieces  and  devours  them.  In  some  cases, 
which  are  rare  but  very  important  from  the  medico- 
legal point  of  view,  the  criminal,  act  appears  to  be 
prompted  by  the  usual  sentiments  of  the  patient.1 
Suicide  is  sometimes  observed; 

(e)  Amnesia,  which  is  usually  absolute,  following  the 
attack.  All  classical  descriptions  show  that  the  patients 
are  as  a  rule  totally  ignorant  of  the  damage  or  of  the 
crimes  which  they  have  committed.  This  rule,  however, 
has  some  exceptions.  The  patient  may  have  a  recollec- 
tion, most  frequently  very  vague,  of  the  acts  accom- 
plished by  him  during  the  attack.  Three  classes  of  cases 
may  present  themselves :  (1)  The  subject  may  retain  a 
complete  or  a  partial  recollection  of  the  delirious  period, 
which  persists  as  an  ordinary  impression;  (2)  the 
recollection,  present  immediately  after  the  attack,  may 
be  subsequently  effaced,  and  the  patient  denies  facts 
which  he  previously  admitted  to  be  true ;  (3)  inversefy, 
the  recollection,  absent  at  the  time  when  the  patient 
comes  to,  may  appear  later  on:  the  patient  admits  a 
fact  which  he  previously  denied.  The  recollections  of 
epileptic  delirium  are  thus  similar  to  those  of  ordinary 

1  Fere.     hoc.  cit.,  p.  144, 


316  MANUAL  OF  PSYCHIATRY. 

dreams.  We  may  forget  within  a  few  hours  a  dream 
which  we  remembered  very  clearly  at  the  time  of  awaken- 
ing; or,  more  rarely,  we  may,  on  the  contrary,  recollect  a 
dream  which  previously  seemed  to  have  left  no  impres- 
sion whatever  upon  the  mind. 

An  attack  of  epileptic  delirium  lasts  from  a  few 
minutes  to  several  days.  It  may  be  reduced  to  a 
single  automatic  act.  Like  the  other  manifestations 
of  epilepsy,  it  may  be  produced  always  by  the  same 
external  influences  and  assume  the  same,  form  each 
time.     This  is  of  course  far  from  being  always  the  case. 

The  termination  of  the  delirium  is  either  sudden, 
following  a  profound  sleep,  or  gradual,  leaving  for 
several  hours  delusions  and  hallucinations  which  persist 
in  spite  of  the  return  of  lucidity. 

The  above  is  a  description  of  the  most  common,  one 
may  say  classical,  form  of  epileptic  delirium.  Another 
form  is  occasionally  met  with  in  which  ideas  of  grandeur 
occur  in  place  of  the  painful  delusions ;  these  ideas  often 
assume  a  mystic  character  and  are  associated  with  a 
state  of  euphoria  which  may  reach  the  intensity  of 
ecstasy. 

The  diagnosis  is  very  easy  when  these  phenomena 
appear  in  an  old  epileptic;  it  becomes  very  difficult, 
however,  when  the  epilepsy  is  "  masked,  or  atypical  in 
its  course."  * 

There  is  no  pathognomonic  sign  of  epileptic  delirium 
excepting,  perhaps,  the  consecutive  stupor  the  impor- 
tance of  which  is  justly  insisted  upon  by  Samt  and 
Moeli.2     However,  this  stupor  maj^  be  so  slight  as  to 

1  Magnan.     Loc.  tit.,  p.  2. 

2  Allg.  Zeitsch.  f.  Psychiat.,  1900,  Nos.  2  and  3. 


EPILEPSY.  317 

escape  the  observation  of  those  witnessing  the  attack. 
The  previous  history  of  the  patient  may  contain  nothing 
to  aid  the  diagnosis  because  the  delirium  sometimes 
constitutes  the  first  manifestation  of  epilepsy;  on  the 
other  hand,  epileptics  may  present  mental  disturbances 
which  have  nothing  in  common  with  their  disease 
(alcoholic  delirium,  chronic  delirium).  Only  upon  the 
entire  symptom  complex  together  with  the  previous  history 
of  the  patient  can  the  diagnosis  of  the  delirium  or  of  any 
other  epileptic  manifestation  be  established. 

We  may  distinguish : 

Delirium  tremens  by  the  occupation  delirium,  by  the 
intact  autopsy  chic  orientation,  and  by  the  stigmata  of 
chronic  alcoholism ; 

States  of  transitory  obnubilation,  encountered  in 
chronic  alcoholism,  by  absence  of  the  subsequent 
stupor  (Moeli); 

Delirious  attacks  of  general  paresis,  which  may  resemble 
epileptic  delirium,  by  the  patient's  previous  history  and 
especially  by  the  presence  of  the  special  physical  signs 
of  this  affection; 

Mania  by  the  flight  of  ideas; 

Attacks  of  catatonic  excitement  by  the  relative  con- 
servation of  lucidity. 

Several  authors,  Krafft-Ebing  among  them,  have 
described  under  the  name  of  transitory  delirium  or 
transitory  mania  very  brief,  non-recurring  delirious 
attacks  which  they  consider  as  a  distinct  morbid  entity. 
The  similarity  between  these  attacks  and  those  of 
epileptic  delirium  is  such  that  most  alienists  consider 
them  as  being  of  epileptic  origin,  at  least  in  the  great 
majority  of  cases.     This  opinion  is  entertained  notably 


318  MANUAL  OF  PSYCHIATRY. 

by  Schwartz,1  Regis,2  and  Vallon.3  According  to  these 
authors  the  cases  of  transitory  delirium  which  are  not 
of  epileptic  origin  are  attributable  to  some  infectious 
disease,  to  alcoholism,  or  to  mental  degeneration.  In 
the  clinic  only  a  close  study  of  the  antecedents  of  a 
given  case  enables  one  to  decide  to  which  of  these 
causes  the  attack  is  due. 

The  etiology  of  epileptic  delirium  is  that  of  epilepsy 
in  general. 

Treatment  of  epilepsy. — We  shall  consider  separately 
the  treatment  of  epilepsy  itself  and  that  of  its  psychic 
complications. 

The  first  really  belongs  to  the  domain  of  neurology, 
and  I  shall  therefore  limit  myself  to  a  mere  statement 
of  the  principal  lines  of  treatment. 

The  treatment  of  epilepsy  comprises: 

(A)  Hygienic  measures; 

(B)  Medicinal  treatment. 

(A)  The  hygiene  of  an  epileptic  consists  in:  (a)  a 
diet  by  which  the  quantity  of  toxines  produced  in  the 
organism  is  reduced  to  the  minimum:  a  partial  milk 
diet,  combined  with  white  meats,  vegetables,  eggs,  is 
of  great  utility;  (b)  the  suppression  of  the  use  of  all 
alcoholic  beverages;  (c)  outdoor  life  with  moderate 
physical  and  mental  labor;  a  mild  but  firm  moral 
direction.  An  effort  should  be  made  to  impress  it 
upon  the  epileptic  that  he  is  subject  to  the  common 
laws  and  that  he  is,  like  everybody  else,  responsible 
for  his  actions. 

Schwartz.     Mania  transitoria,     Allg.  Zeits.  f.  Psychiat.,  1891. 

2  Regis.     Manuel  de  maladies  mentales. 

3  Vallon.     Rapport  au  Congrcs  d' Angers,  1898. 


EPILEPSY.  319 

(B)  Medical  treatment. — Of  all  the  drugs  used  in  the 
treatment  of  epilepsy  I  shall  mention  only  the  bromides 
of  the  alkali  metals,  the  efficacy  of  which  is  incontesta- 
ble, and  opium,  which  has  gained  considerable  reputa- 
tion through  the  recent  introduction  of  a  new  method 
of  treatment. 

The  bromides  of  sodium  and  of  potassium  are  admin- 
istered either  separately  or  in  a  mixture  of  the  two 
with  bromide  of  ammonium,  which  mixture  is  some- 
times known  as  the  "tribromide."  The  doses  vary 
according  to  the  age,  the  frequency  of  the  attacks, 
and  the  tolerance  of  the  subject.  The  maximum  that 
may  be  administered  to  an  adult  with  benefit  seems 
to  be  from  8  to  10  grams  daily.  Usually  good  results 
can  be  obtained  from  moderate  doses — from  3  to  6 
grams  daily. 

The  action  of  the  bromides  seems  to  be  more  pro- 
nounced when  the  patient  is  allowed  a  "  hypochloriza- 
tion"  diet;  that  is  to  say,  a  diet  in  which  the  amount 
of  sodium  chloride  is  reduced  so  far  as  possible  (Richet 
and  Toulouse). 

Flechsig  introduced  several  years  ago  a  method  of 
treatment  consisting  in  the  administration  of  increasing 
doses  of  opium  and  finally  in  suddenly  suppressing  the 
drug.  This  procedure  suspends  the  attacks  in  some 
cases  for  a  very  long  time.  Unfortunately  their  recur- 
rence is  always  to  be  feared. 

Treatment  of  the  mental  disorders. — The  first  question 
which  arises  is:  Should  an  epileptic  be  committed? — 
Yes,  in  two  classes  of  cases:  (1)  If  the  seizures  are 
accompanied  by  marked  delirious  disorders;  (2)  If, 
independently  of  the  seizures,  the  patient  is  subject 


320  MANUAL  OF  PSYCHIATRY. 

to  violent  impulses.  Epileptic  imbeciles  and  idiots 
come  under  the  same  rule. 

During  the  delirious  attacks  the  patient  is  to  be 
constantly  watched.  Unfortunately  rest  in  bed  can 
be  instituted  only  with  great  difficulty  on  account  of 
the  profound  clouding  of  consciousness.  Prolonged 
baths  and  the  prudent  use  of  hypnotics  are  here 
especially  indicated.  Refusal  of  food  and  threatening 
collapse  are  to  be  treated  by  ordinary  methods. 

Responsibility. — An  epileptic  is  not  to  be  considered 
as  absolutely  irresponsible  except  in  the  following 
three  cases:  (1)  If  the  act  which  he  is  accused  of  is 
committed  during  a  delirious  attack;  (2)  if  he  is  a 
dement;    (3)  if  he  is  an  idiot  or  an  imbecile. 

If  the  act  is  committed  during  a  lucid  interval 
and  if  outside  of  the  attacks  the  patient  presents  no 
evident  signs  of  intellectual  enfeeblement  he  should 
be  considered  responsible,  at  least  partially  so  if  an 
allowance  is  to  be  made  for  his  irritable  and  impulsive 
disposition.1 

Similarly,  an  epileptic  ought  not  be  excluded  from 
spheres  of  social  activity  unless  he  presents  some  per- 
manent mental  disorder. 


1  See   the   remarkable    case   reported   by  Motet   in  Ann.  d'hyg. 
publiq.  et  de  med.  leg.,  1882. 


CHAPTER  XVI. 
HYSTERIA. 

To  make  a  complete  study  of  the  mental  disorders 
of  hysteria  would  mean  a  consideration  of  the  entire 
clinical  history  of  this  neurosis,  for  hysteria  is  essentially 
a  mental  affection.  It  is,  however,  the  custom  to 
leave  a  considerable  portion  of  this  subject  to  neurology, 
reserving  for  psychiatry  the  phenomena  belonging  to  its 
own  sphere,  not  only  from  its  origin,  but  also  from  its 
aspect.  The  paralyses,  contractures,  anaesthesias,  in 
a  word  all  the  somatic  symptoms,  will  therefore  be 
systematically  omitted  from  the  following  description. 

The  mental  disorders  of  hysteria  are  all  dependent 
upon  the  predominance  of  the  automatism  over  the  volun- 
tary and  conscious  psychic  operations.  These  disorders 
are  divided  into  the  permanent  and  the  paroxysmal. 

Permanent  mental  disorders. — These  constitute  the 
mental  stigmata  of  Janet,1  and  impart  to  the  personality 
of  the  hysterical  subject  its  peculiar  clinical  aspect. 
The  following  are  the  principal  ones: 

(a)  Enfeeblement  and  mobility  of  the  attention,  which 
no  longer  directs  the  associations  of  ideas,  thus  leaving 
uncontrolled  the  mental  automatism.     In  some  cases 


1  Pierre  Janet.     Etat  mental  des  hysteriques. 

321 


322  MANUAL  OF  PSYCHIATRY. 

the  patient  lives  as  in  a  dream  in  which  the  images  and 
ideas  follow  each  other  without  order  or  logical  sequence. 
In  other  cases  the  automatism  assumes  the  form  of  a 
fixed  idea  upon  which  the  affective  phenomena  and 
the  reactions  are  dependent.  Almost  always  subcon- 
scious, the  hysterical  fixed  idea  requires  a  careful 
search  for  its  discovery  and  often  cannot  be  revealed 
except  during  the  hypnotic  sleep. 

(6)  Disorders  of  the  memory;  amnesia  of  reproduction: 
Recollections  can  not  be  evoked  at  will  though  they 
may  still  arise  automatically;  the  amnesia  of  repro- 
duction is  often  partial  and  in  its  course  is  subject  to 
numerous  remissions  and  exacerbations;  its  duration 
is  very  variable,  from  a  few  minutes  to  several  years; 
illusions  and  hallucinations  of  memory  form  the  basis 
of  imaginary  recollections,  remarkable  for  their  precision, 
their  wealth  of  detail,  and  their  quite  probable  character: 
they  result  from  the  extreme  suggestibility  and  often 
originate  from  a  story  the  patient  has  read  or  from  an 
event  narrated  in  his  presence. 

(c)  Changes  in  the  affectivity  and  character:  Morbid 
indifference  associated  with  great  variability  of  moods, 
egoism,  susceptibility,  and  a  morbid  desire  to  attract 
attention.  The  hysterical  subject  thus  resembles  closely 
the  constitutional  psychopath:  both  bear  the  stamp  oi 
marked  mental  degeneration,  and  they  belong  to  two 
closely  related  groups  of  individuals  predisposed  to 
mental  alienation. 

The  morality  of  hysterical  subjects  has  been  much 
discussed  with  special  reference  to  their  duplicity  and 
tendency  to  prevarication.  Some  see  in  the  falsehoods 
of  the  patients  nothing  but  errors  attributable  to  the 


HYSTERIA.  323 

amnesia;  others,  less  tolerant,  consider  these  falsehoods 
as  intentional,  and  see  in  them  a  sign  of  perversity. 
Both  opinions  are  partly  true.  It  is  certain  that  these 
patients  often  commit  errors  unconsciously,  but  it  is 
none  the  less  certain  that  they  prevaricate  knowingly. 
The  common  phrase  hysterical  lying  is  not  an  unjustified 
one. 

(d)  Anomalies  of  the  sexual  life:  Sometimes,  much  less 
frequently  than  is  commonly  supposed,  hysterical  sub- 
jects present  erotic  tendencies;  much  more  often  there 
is  frigidity  with  or  without  sexual  perversion. 

(e)  Enfeeblement  of  the  will:  Aboulia  is  a  constant 
phenomenon  and  is  apparent  in  the  apathy  and  negli- 
gence. Though  occasionally  the  patient  gives  evidence 
of  feverish  activity,  the  duration  of  this  activity  is  but 
brief  and  the  subsequent  reaction  is  marked  by  an 
exaggeration  of  the  aboulia. 

Automatic  reactions  replace  the  voluntary  ones  and 
are  manifested  in  the  most  varied  forms:  pathological 
suggestibility,  catalepsy,  passionate  impulses,  etc. 

Episodic  mental  disorders. — These  may  either  accom- 
pany the  hysterical  attacks  or  occur  independently 
of  them. 

(a)  Mental  disorders  associated  with  the  attacks. — These 
are: 

(1)  Before  the  crisis:  an  accentuation  of  the  ordinary 
anomalies  of  the  character:  sometimes  appears  a  hallu- 
cination, a  fixed  idea. 

(2)  During  the  crisis:  hallucinations,  delusions,  motor 
excitement  may  partly  or  completely  replace  the  or- 
dinary hysterical  phenomena  (maniacal  or  ecstatic  form 
of  crisis) . 


324  MANUAL  OF  PSYCHIATRY. 

(3)  After  the  crisis:  a  delusional  state  associated  with 
multiple  combined  hallucinations  which  are  often  of  an 
erotic  nature  and  which  may  give  rise  to  passionate 
attitudes  and  movements. 

(b)  Among  the  mental  disorders  occurring  independently 
of  the  attacks  an  important  one  is  somnambulism,  spon- 
taneous or  induced;  it  presents  the  most  perfect  form 
of  psychic  automatism. 

Closely  related  to  the  states  of  somnambulism  are 
the  states  of  obscuration,  which  present  themselves  in 
two  different  forms:  (a)  the  stupid  form,  characterized 
by  mental  hebetude  and  absence  of  reactions;  (/?)  the 
agitated  form,  characterized  by  violent  reactions  and 
excitement  associated  with  confused  delirium.  Some- 
times the  excitement  is  so  pronounced  as  to  simulate 
epileptic  delirium.  The  duration  of  the  attack  is 
scarcely  ever  more  than  a  few  days. 

Hysterical  subjects  may  also  have  acute  attacks 
resembling  manic  depressive  insanity,  which  are  known 
as  hysterical  mania  and  melancholia .  I  shall  return  to 
this  subject  in  connection  with  the  differential  diagnosis. 

A  positive  diagnosis  of  the  hysterical  mental  disorders 
is  chiefly  to  be  based  upon  the  existence  of  the  psychical 
stigmata  mentioned  at  the  beginning  of  this  chapter 
and  of  the  physical  stigmata  which  are  described  in 
all  works  on  neurology:  clavus  or  globus  hystericus, 
ovaralgia,  anaesthesia,  monoplegia,  visceral  disorders 
such  as  obstinate  vomiting,  palpitation,  etc. 

The  differential  diagnosis  is  sometimes  very  difficult  to 
make  from  the  following  conditions: 

(a)  Catatonia. — The  problem  is  a  complicated  one, 
since  most  of  the  catatonic  phenomena  may  be  en- 


HYSTERIA.  325 

countered  in  hysteria,  also  most  of  the  hysterical 
symptoms,  nervous  or  psychical,  may  occur  in  catatonia. 
The  only  certain  differential  feature  is  the  intellectual 
enfeeblement,  which  is  almost  constant  in  catatonia  and 
altogether  exceptional  in  hysteria.  Before  its  appear- 
ance the  diagnosis  remains  doubtful,  and  can  only  be 
surmised  from  the  following  features :  psychic  disaggre- 
gation is  more  marked  in  catatonia,  resulting  in  true 
incoherence;  the  symptoms  in  catatonia  have  a  more 
stable  character;  stereotypy  is  more  marked;  the 
moral  indifference  is  more  pronounced;  there  is  no 
subconscious  fixed  idea. 

(b)  Epilepsy. — The  unconsciousness  during  the  seizure, 
the  subsequent  amnesia,  which  is  more  constant  and 
more  complete  in  epilepsy  than  it  is  in  hysteria,  and 
the  nature  of  the  convulsive  seizures  serve  as  a  basis 
for  the  diagnosis,  which  is  in  some  instances  very  diffi- 
cult to  establish.  Moreover  it  seems  that  hysteria  and 
epilepsy  may  exist  together  in  the  same  subject. 

(c)  Mania. — Here  the  excitement  is  usually  more 
continuous  and  less  affected  by  external  influences, 
such  as  the  presence  of  spectators,  which  always  increases 
the  excitement  of  hysteria;  the  flight  of  ideas  is  much 
more  distinct;    hallucinations  are  more  rarely  seen. 

(d)  Melancholic  depression. — The  depression  is  con- 
tinuous and  durable  and  is  independent  of  external 
influences,  while  in  the  hysterical  patient  a  pleasantry 
or  a  word  of  encouragement  often  suffices  to  dissipate, 
at  least  momentarily,  the  melancholic  phenomena. 
The  manifestations  of  psychic  automatism  are  much 
less  marked  in  melancholic  depression  than  in  hysteria. 

The   prognosis   of   hysteria   is   grave.     The   episodic 


326  MANUAL  OF  PSYCHIATRY. 

mental  disorders  usually  subside,  either  spontaneously 
or  under  the  influence  of  treatment;  but  the  hysterical 
disposition  remains  and  renders  the  recurrence  of 
the  attacks  probable. 

The  treatment 1  consists  in  rest,  isolation,  hydro- 
therapy, and  therapeutic  suggestion,  which,  with  or 
without  hypnosis,  produces  marvelous  results;  also 
attention  to  the  somatic  disturbances  so  frequent  in 
hysteria  is  of  importance. 

Excitement  is  to  be  treated  by  the  usual  methods. 
Isolation  often  produces  very  happy  results. 

1  Sollier.     L'hysterie  et  son  traitement.     Paris,  F.  Alcan. 


CHAPTER  XVII. 
ARRESTS  OF  DEVELOPMENT. 

Like  the  constitutional  psychopaths,  the  feeble- 
minded belong  to  that  class  of  degenerates  who  enter 
into  life  with  a  mental  disorder  which  is  not  merely 
potential  but  actual. 

Etiology. — All  the  causes  mentioned  in  the  chapter 
on  general  etiology  as  being  capable  of  giving  rise  to 
degeneration  may  bring  about  an  arrest  of  develop- 
ment, if  this  action  is  exercised  during  intrauterine 
life  or  during  the  early  years  of  extrauterine  life.  In 
the  latter  case  the  affection  is  in  reality  an  acquired 
one,  but  is  clinically  practically  identical  with  the 
congenital  form. 

Two  factors,  however,  deserve  special  mention: 
alcoholic  heredity  and  syphilitic  heredity.  Alcoholism 
in  all  its  forms  is  encountered  in  the  parents  of  idiots 
and  imbeciles:  chronic  alcoholism,  drunkenness  at 
the  moment  of  conception  or  during  pregnancy,  etc. 
Recent  statistics  compiled  by  Bourneville  show  that 
48%  of  idiots  and  imbeciles  are  the  offspring  of  alcoholic 
parents. 

Syphilitic  heredity  may  act  in  two  ways :   either  by 

giving  rise  to  a  congenital  anomaly  through  intrauterine 

disorders  or  by  causing  the  appearance   of  meningeal 

327 


328  MANUAL  OF  PSYCHIATRY. 

and  cerebral  lesions  during  the  first  months  of  life 
of  which  the  arrest  of  development  is  the  consequence. 
Two  kinds  of  arrest  of  development  are  distinguished: 
(1)  A  general  arrest  of  development  involving  all  the 
psychic  functions;  three  degrees  are  usually  recognized: 
idiocy,  imbecility,  and  feeble-mindedness;  (2)  an  arrest 
of  development  which  is  almost  wholly  limited  to  the 
moral  sphere — moral  insanity. 

§  1.  General  Arrest  of  Development:   Idiocy, 
Imbecility,  Feeble-mindedness. 

First  Manifestations. — According  to  Sollier,  who  has 
made  an  extensive  study  of  these  anomalies,  the  prin- 
cipal early  manifestations  are : 

(a)  A  difficulty  in  taking  the  breast;  it  seems  each 
time  that  the  act  is  a  new  one  to  the  child; 

(b)  Violent,  continued,  and  unprovoked  crying; 

(c)  An  impossibility  of  fixing  the  gaze; 

(d)  A  lack  of  expression  in  the  physiognomy. 

Later  on,  at  the  age  when  intelligence  becomes  mani- 
fest in  normal  children,  the  signs  of  psychic  insufficiency 
become  more  and  more  evident.  The  child  is  sad,  surly, 
or,  on  the  contrary,  extraordinarily  noisy  and  turbulent. 
It  does  not  speak  or  it  may  be  able  to  say  only  a  few 
words  at  an  age  when  other  children  already  dispose  of 
quite  a  vocabulary.  Still  more  important  than  the 
language  of  transmission  is  that  of  reception.  The 
chief  characteristic  of  the  congenital  imbecile  is  the 
restricted  number  of  words,  not  which  he  can  pro- 
nounce, but  which  he  can  understand. 

Physically,  arrest  of  development  manifests  itself  in 


ARRESTS  OF  DEVELOPMENT.  329 

a  retardation  of  the  growth,  of  the  development  of  the 
hairy  system,  and  especially  of  learning  how  to  walk. 

Symptoms. — As  with  the  growth  of  the  child  the 
psychic  functions  become  of  greater  importance,  their 
insufficiency  becomes  more  apparent  and  manifests 
itself  in  the  impossibility  for  the  subject  to  derive  any 
benefit  from  education. 

This  incapacity  is  due  to  absence  or  weakness  of  atten- 
tion (Sollier),  so  that  the  degree  of  atrophy  of  this 
faculty  can  serve  as  a  basis  for  the  classification  of 
arrests  of  development.     Sollier  distinguishes: 

(1)  Absolute  idiocy:  complete  absence  and  impossibility 
of  attention; 

(2)  Simple  idiocy:  weakness  and  difficulty  of  atten- 
tion; 

(3)  Imbecility:  instability  of  attention. 

We  may  add  also  jeeble-mindedness,  in  which,  as  in 
imbecility,  the  attention  is  unstable,  though  to  a  less 
marked  degree. 

Atrophy  of  the  attention  is,  therefore,  the  most 
important  symptom  of  arrest  of  psychic  development.1 

Around  this  is  grouped  a  certain  number  of  other 
symptoms  which  I  shall  mention  briefly: 

(a)  Sluggishness  and  lack  of  variety  in  the  psychical 
processes,  entailing  an  insufficiency  of  judgment  and  an 
absence  or  rarity  of  generalized  ideas.  The  latter  two 
symptoms  are  most  striking  in  the  feeble-minded. 

(b)  Weakness  and  inaccuracy  of  the  memory.  An  idiot 
or  an  imbecile  is  seldom  able  to  relate  correctly  an  event 
that  he  has  witnessed.     The  details  and  even  the  facts 


Sollier.     Psychologie  de  V idiot  et  de  V imbecile.     Paris,  F.  Alcan. 


330  MANUAL  OF   PSYCHIATRY. 

themselves  are  altered.  Quite  frequently  imbeciles 
relate  imaginary  recollections  which  indicate  by  their 
monotonous  and  childish  character  a  very  poor  imagina- 
tion. 

(c)  Moral  indifference  associated  with  morbid  irrita- 
bility (this  symptom  is  to  be  looked  upon  as  an  expression 
of  a  disorder  of  the  moral  sense),  impulsive  character  of  the 
reactions,  and  extreme  suggestibility  of  the  will;  this  latter 
disorder  together  with  the  weak  memory,  insufficient 
judgment,  and  atrophied  moral  sense  renders  the  testi- 
mony of  an  idiot  or  an  imbecile  acceptable  only  with 
extreme  caution. 

(d)  Disorders  of  language.  In  the  lowest  grade  of 
idiocy  language  is  absent.  In  simple  idiocy  and  in 
imbecility  we  usually  find: 

(1)  A  vocabulary  that  is  more  restricted  than  in 
normal  individuals  of  the  same  age  and  under  the 
same  conditions; 

(2)  Errors  of  syntax  which  are  at  times  very  curious. 
Some  idiots  make  use  of  faulty  construction:  "Me  no 
sick, v  etc.  Others  never  use  the  pronouns  /,  you,  he,  etc., 
referring  to  themselves  and  to  others  by  their  proper 
names.  One  imbecile,  Elise  B.,  used  to  say,  "Elise  B. 
is  going  to  bed. "  The  substitution  of  a  pronoun  for  a 
proper  name  is  an  intellectual  operation  impossible  for 
these  patients.  In  the  pronunciation  we  often  notice 
lisping,  stammering,  and  stuttering.  Written  language, 
necessitating  very  complex  associations,  is  still  less 
developed  than  spoken  language.  Many  imbeciles  are 
unable  to  read,  and  only  few  are  able  to  write  properly. 
Writing  necessitates  delicate  movements  in  addition  to 
the  difficulties  of  reading.     Mimicry,  the  most  elemen- 


ARRESTS  OF  DEVELOPMENT.  331 

tary  of  all  forms  of  language,  is  least  affected.  Usually, 
however,  it  has  not  the  same  liveliness  as  in  the  normal 
individual.  A  single  glance  suffices  to  distinguish  the 
idiot  who  does  not  speak  from  the  intelligent  deaf-mute. 

These  are  the  essential  and  fundamental  features  of 
idiocy  and  imbecility.  They  may  present  all  degrees, 
from  complete  idiocy  in  which  the  mentality  of  the 
individual  is  inferior  to  that  of  an  animal  to  slight  feeble- 
mindedness which  is  compatible  with  a  normal  social 
existence.  These  extremes  are  connected  by  an  infinity 
of  intermediate  degrees,  so  that  no  distinct  lines  of 
demarcation  can  be  drawn  between  idiocy,  imbecility, 
and  simple  feeble-mindeclness. 

All  the  mental  faculties  are  not  always  atrophied  to 
the  same  extent.  The  memory  is  sometimes  quite 
good,  occasionally  even  exceptionally  so.  "  Forbes 
Winslow  (quoted  by  Sollier)  reports  a  case  of  an  idiot 
who  could  recall  the  dates  of  death  of  all  those  who  died 
in  his  town  during  thirty-five  years,  giving  correctly 
their  names  and  ages."  Some  imbeciles  present  rela- 
tively remarkable  aptitudes  for  the  arts,  especially 
for  music.  They  retain  with  surprising  facility  com- 
plicated pieces  of  music,  and  are  able  to  reproduce 
them  passably  well  on  an  instrument.  Still  they  neATer 
acquire  a  true  talent,  for  they  lack  the  attention  which 
is  necessary  for  the  development  of  their  natural  apti- 
tudes. 

Physically,  all  the  anatomical  stigmata  of  degenera- 
tion may  be  met  with  in  idiots  and  imbeciles. 

The  sexual  instinct  is  absent  (lowest  type  of  idiocy), 
or  abnormally  developed,  or  perverted.  Many  idiots  and 
imbeciles  are   addicted  to  masturbation,  to  pederasty, 


332  MANUAL  OF  PSYCHIATRY. 

or  have  a  tendency  to  commit  acts  of  rape,  exhibition- 
ism, sadism,  etc. 

Filthy  habits  are  frequent:  the  patients  soil  and 
wet  themsevles.  Often  this  symptom  is  only  nocturnal 
and  can  be  combated  by  constant  supervision. 

Complications. — These  are  somatic  and  psychical. 

The  former  arise  from  defects  of  development  or 
from  a  low  resistance  of  the  organism.  They  are,  on 
the  one  hand,  the  malformations  constituting  the 
physical  signs  of  degeneration,  and,  on  the  other  hand, 
various  infections  occurring  upon  a  basis  of  poor  nutri- 
tion of  the  tissues. 

Among  the  sequelae  left  behind  by  the  infections  a 
prominent  place  belongs  to  permanent  lesions  of  the 
brain  and  cord,  which  give  rise  to  phenomena  of  paral- 
ysis, atrophy,  etc.  (infantile  hemiplegia,  infantile  palsy, 
strabismus).  These  disorders  are  often  coincident  in 
time  with  the  mental  disorders  and  are  dependent  upon 
the  same  causes. 

Epilepsy  forms  a  transition  between  the  somatic 
and  the  psychic  complications.  The  frequency  of 
infantile  convulsions  in  the  histories  of  those  of  arrested 
development  in  itself  shows  the  close  relationship 
existing  between  epilepsy  and  arrested  development. 
Epileptic  seizures  are  frequent  among  idiots  and  imbe- 
ciles. The  commotion  which  the  seizures  exercise 
upon  the  psychic  function  leads  to  an  accentuation  of 
the  mental  debility.  The  imbecile  becomes,  in  addi- 
tion, an  epileptic  dement. 

Most  of  the  mental  maladies  may  occur  in  those  of 
arrested  development,  though  this  is  not  very  fre- 
quent:    general     paresis,     dementia     prsecox,     manic 


ARRESTS  OF  DEVELOPMENT.  333 

depressive  insanity.  All  these  affections  render  even 
more  apparent  the  nature  of  the  soil  by  the  poverty 
and  emptiness  of  the  delusions  and  the  absence  of  all 
systematization. 

Prognosis,  diagnosis,  treatment. — Arrests  of  develop- 
ment are  not  diseases,  but  infirmities;  their  prognosis 
is,  therefore,  grave.  Education  may,  however,  exer- 
cise a  favorable  influence  upon  some  subjects. 

The  elements  of  diagnosis  are  to  be  found  in  the 
history  of  the  subject;  the  absence  of  any  vestige  of 
more  complete  intellectual  development  previous  to 
the  time  of  examination  must  be  established. 

The  principal  indications  for  treatment  are :  to  develop 
the  subject's  attention,  and  to  give  a  proper  direction 
to  the  automatism  which  dominates  his  reactions. 
This  aim  is  unfortunately  more  easily  pointed  out 
than  attained.  Considerable  success  has,  however, 
been  obtained  in  recent  times  by  means  of  special 
methods  of  education. 

§  2.  Moral  Insanity. 

By  reason  of  its  complexity  the  moral  sense  is  one 
of  the  most  delicate  and  most  vulnerable  functions 
of  the  mind.  Thus  we  find  it  altered  in  most  of  the 
psychoses,  especially  in  those  accompanied  by  intel- 
lectual enfeeblement. 

The  symptoms  which  alterations  in  the  moral 
sense  give  rise  to  do  not  merit  the  name  of  moral  in- 
sanity unless  they  exist  in  an  isolated  state  or 
at  least  are  not  associated  with  any  other  apparent 
mental  disorder.    I  say  apparent,  because  close  obser- 


334  MANUAL  OF  PSYCHIATRY. 

vation  almost  always  reveals  the  existence  in  the  sub- 
ject of  certain  physical  and  psychical  peculiarities 
which  show  that  the  anomaly  extends  beyond  the 
moral  sphere. 

Moral  insanity  finds  early  expression  in  perversities 
of  the  character  and  conduct.  The  child  is  naughty, 
cruel,  deceitful,  irritable,  violent;  or  he  is,  on  the  con- 
trary, taciturn  and  dissembling. 

Education  totally  fails  to  modify  such  natures.  The 
moral  sense  is  not  built  up  upon  notions  acquired 
through  intellectual  culture.  It  is  the  result  of  a 
special  sensibility,  of  a  function  which  the  psychical 
organ  lacks  in  moral  insanity.  "  When  this  apparatus 
is  absent,  the  most  favorable  surroundings  fail  to 
exert  their  influence."  * 

As  the  child  becomes  a  man,  as  he  comes  into  more 
direct  contact  with  society,  his  infirmity  becomes  more 
manifest. 

The  dominant  feature  of  moral  insanity  is  a  pro- 
found egoism  combined  with  a  complete  indifference 
with  regard  to  good  and  evil. 

The  exclusive  aim  of  such  an  individual  is  his  pleasure 
or  his  own  interest  (and  quite  often  he  has  but  very 
poor  judgment  as  regards  even  his  own  interests),  and  to 
reach  this  aim  he  does  not  hesitate  to  use  any  means  or 
any  expedient.  He  has  neither  any  sentiment  of  honor 
nor  any  respect  for  the  truth.  His  unique  preoccupa- 
tion is  to  escape  conviction  and  punishment. 

Cruel  and  malicious  toward  his  inferiors  and  towards 


1  Bleuler.     Der  geborene  Verbrecher.     Eine  kritische  Studie,  1S96. 
p.  21. 


ARRESTS  OF  DEVELOPMENT.  335 

the  weak  in  general,  he  is  cowardly  towards  anybody 
who  is  above  him.  In  the  asylum  or  prison  he  quite 
readily  submits  to  the  rules  and  to  the  discipline  and 
does  not  abandon  himself  to  his  morbid  propensities 
until  he  regains  his  liberty. 

Undoubtedly  there  are  cases  of  moral  insanity  with 
a  sane  judgment  and  a  strong  will.  These,  freed  from 
the  scruples  which  might  interfere  with  their  liberty 
of  action,  occasionally  have  a  brilliant  career. 

Almost  always,  however,  other  psychical  anomalies 
are  present  in  addition  to  the  disorders  of  the  moral 
sphere.     The  most  frequent  are: 

(a)  Weakness  of  judgment:  the  subject  realizes  but 
imperfectly  the  possible  consequences  of  his  acts,  and 
in  spite  of  all  his  precautions  he  ultimately  enters  into 
conflict  with  the  law.  ""The  thoughtlessness  of  crim- 
inals" is  well  known. 

(b)  Absence  of  perseverance:  this  prevents  the  utili- 
zation of  the  faculties  which  the  patient  may  pos- 
sess and  which  are  in  some  instances  very  well  de- 
veloped. 

(c)  Impulsiveness:  the  moral  insane  readily  yield  to 
the  first  impulse,  so  that  it  is  quite  difficult  in  practice 
to  distinguish  them  from  the  impulsive  criminals.  The 
best  criterion  is  the  existence  of  subsequent  remorse  in 
the .  latter.  Unfortunately  it  is  impossible  to  deter- 
mine its  true  degree  of  sincerity.  It  is  well  known 
with  what  consummate  art  hardened  criminals  simu- 
late the  most  touching  remorse. 

(d)  Diverse  psychical  anomalies:  obsessions,  mor- 
bid emotionalism,  etc. 

The  physical  signs  of  degeneration  are  frequent. 


336  MANUAL  OF  PSYCHIATRY. 

Commitment  is  in  most  cases  necessary.  Agricultural 
colonies,  properly  conducted,  are  admirably  suited  for 
this  class  of  patients.  Moral  treatment,  properly  so 
called,  has  no  effect. 


APPENDIX. 


A  SCHEME  FOR  THE  STUDY  OF  THE  HISTORY  AND 
OF  THE  MENTAL  AND  PHYSICAL  STATUS  OF 
CASES   OF  MENTAL   DISTURBANCE.1 


I.    FAMILY  HISTORY. 


The  family  in  gen- 
eral (collater- 
als, ASCENDANTS, 
DESCENDANTS) . 


Mental  diseases. — Nervous  diseases. 
Anomalies  of  character  and  of  morality. 
— Irritability  or  mobility  of  moods. — 
•I  Excessive  originality ;  eccentricities  in  the 
conduct. — Criminality. 
Congenital  malformations. 
I  Arthritic  manifestations. 


the  ascendants  in 
general  (grand- 
parents  and 
parents). 


Intoxications:    Alcoholism,  morphinism, 

etc. 
Infectious  diseases,  in  particular  syphilis 

and  tuberculosis. 
Overwork . — Grief. 
Traumatisms,    especially    those    of    the 

cranium. 


1  [As  the  book  was  going  to  the  press,  with  all  the  plates  ready,  I 
received  from  the  author  a  copy  of  the  second  French  edition.  Most 
of  the  additions  consist  in  citations  of  illustrative  cases.  This 
scheme  may  prove  of  considerable  utility  in  the  study  of  cases,  and 
I  have  therefore  embodied  it  in  the  translation  in  the  form  of  an 
appendix. — A.  J.  R.] 

337 


338 


APPENDIX. 


Parents      (father 
and  mother). 


Is  the  patient  an  illegitimate  child? 
Abnormal  conditions  in  the  parents  at  the 
moment  of  conception:  overwork, 
worry,  grief;  intoxications,  especially 
drunkenness;  prodromal  or  convales- 
cent stage  of  mental  or  somatic  disease ; 
confirmed  psychopathic  state- 
Advanced  age  of  one  or  both  parents;  ex- 
cessive difference  between  the  ages  of 
the  two  parents. 


Mother. 


Conditions  under  which  pregnancy  has 
developed  and  terminated :  abnormally 
severe  pains;  uncontrollable  vomiting; 
persistence  of  menstruation;  infectious 
diseases;  albuminuria;  eclampsia;  ner- 
vous and  mental  accidents:  change  of 
disposition,  obsessions  (morbid  long- 
ings) ,  hysterical  or  epileptic  phenomena, 
chorea;  overwork;  traumatisms;  vio- 
lent or  prolonged  emotions. 


Descendants. 


Sterility. 

Abortions  or  miscarriages  in  the  patient 

or  in  the  patient's  wife. 
Still-births. — Death   of    children   at 

early  age. 
Signs  of  syphilis  in  the  children. 
Nervous  disorders:   convulsions,  etc. 
Anomalies  of  development,  physical 

mental. 


an 


or 


II.     PERSONAL  HISTORY. 


Birth. 


r  Premature  birth. 

Is  the  patient  one  of  a  pair  of  twins? 

Character  of  labor:    duration,  abnormal 

presentation,  forceps  operation,  etc. 
.  Vitality  at  the  moment  of  birth. 


APPENDIX. 


339 


Physical   develop- 
ment. . 


Hygienic  conditions  in  infancy  and  child- 
hood. 

Growth:  rapid,  retarded. 

Development  of  the  hairy  system. 

Dentition:  precocious,  retarded,  accom- 
panied by  nervous  accidents. 

Age  at  which  the  child  began  to  walk. 

Age  at  which  the  child  became  cleanly 
(with  regard  to  urination  and  defeca- 
tion). 


Puberty. 


Date  of  onset. 

Accompanying  changes  of  the  character. 

Mental  or  nervous  complications :  epilep- 
tic, hysterical,  or  neurasthenic  manifes- 
tations;     obsessions,     scruples;      psy- 
choses. 
L  Masturbation. 


Psychic 

MENT. 


DEVELOP- 


Language:  At  what  age  has  the  patient 
begun  to  speak  and  especially  to  under- 
stand? 

Studies:  Has  he  learned  easily  to  read  and 
write?  Was  he  attentive?  Was  he 
considered  intelligent? 

Degree  of  success  in  college  or  in  appren- 
ticeship, as  the  case  may  be,  and  further 
in  the  pursuit  of  his  occupation. 

Affectivity:  Indifference;  perversion, — 
cruelty  towards  others  or  towards  ani- 
mals; exaggerated  emotional  irrita- 
bility; phobias;  morbid  affection  for 
animals. 

Disposition:  Excessive  sensitiveness; 
jealousy;  impulsiveness;  changeable 
moods;  irrational  conduct:  numerous 
bizarre  occupations;  changes  of  resi- 
dence or  of  occupation. 


340 


APPENDIX. 


Conditions   of  ex- 
istence. 


'  Occupations  followed  by  patient  with  spe- 
cial reference  to  dangers  involved. — In- 
toxications:    alcoholism,    morphinism; 
lead-poisoning    (house-painters),   phos 
phorus-poisoning,  gas-poisoning,  etc. — 
Infections:    syphilis  (prostitution),  tu- 
berculosis (in  nurses),  etc. — Overwork. 
— Want  of  sleep. — Poor  ventilation. 
Physiological  wants. 
Bad  moral  influences. 

.  Celibacv. 


Pathological     an- 
tecedents. 


r  Diseases  of  childhood :  Infections^ — 
measles,  etc.,  inherited  syphilis;  infan- 
tile marasmus;  rickets;  nervous  and 
mental  accidents  in  early  childhood, — 
convulsions,  meningitis. — Cranial  trau- 
matisms. 

Later  childhood,  youth,  and  adult  age: 
Diverse  somatic  and  psychic  affections. 
In  the  cases  of  previous  attacks  of  men- 
tal disease  inquire  carefully  as  to  the 
supposed  causes,  the  symptoms,  and 
especially  as  to  the  termination  of  each 
attack  (mental  enfeeblement  or  com- 
plete recovery). 

Anomalies  of  the  sexual  instinct. 

In  women,  menstrual  disorders:  irregu- 
larities, accompanying  nervous  or  psy- 
chic disorders,  etc. 


III.    PRESENT  ILLNESS. 


Assigned  causes,  physical  or  moral. 

Mode  of  onset,  sudden  or  following  prodomata. 

First  symptoms  of  mental  disorder  noticed  by  patient  or  by 
his  relatives  or  friends. 

Symptoms  and  course  of  the  disease  up  to  the  time  of  ex- 
amination. 

Treatment  which  the  patient  has  received  and  the  results 
obtained. 


APPENDIX. 


341 


IV.  CLINICAL  EXAMINATION. 

(a)  External  Aspect. 


r  indifferent. 

Facial    expres-^ 

sion  •    i. J  i   i 

irritated. 

I  silly. 

r  friendly. 

Address \  mistrustful. 

I  scornful. 


Manner  and  at- 
titude 


'  dejected. 

humble. 

haughty, 
i  aggressive. 


{neglected, 
neat, 
eccentric. 


(6)  Mental  Status. 

dyzed. 
1  weakened. 


Consciousness    \  \  '__ ,_?__ .  A  Disorientation  \  of  space 


autopsychic. 
of  space 
of  time. 


Perception , 


f  insufficiency. 
( illusions. 


Hallucinations 


conscious  ; 
taken  for  ac- 
tual percep- 
tions. 


Attention (  Paralyzed . 

\  mobile. 

Does  the  patient  grasp  questions  readily? 

r  sluggishness. 
Associations  of  \  flight  of  ideas. 
ideas  1  incoherence. 

I  monoideism. 

Mental  imaqes   I        c     '  i 
y       \  contused. 

Imagination. .  .  {  exalted- 
v  I  diminished. 


Memory 


Affectivity 


{ exalted  (hy- 

j      permnesia). 

diminished 

(amnesia). 

r  abolished. 
\  diminished. 
I  exaggerated. 


C  form. 
I  extent. 
Amnesia  \  mode  of  onset. 

I  origin   (for  instance, 
I     a  fixed  idea). 

Weakening  of  the  moral  sense. 


342 


APPENDIX. 


r  weakened. 

Sexual  instinct.  \  exaggerated. 
I  perverted. 

r  absence  of,  or  imperfect  insight;  imperfect  ap- 

Judgment -j     preciation  of  his  own  actions,  false  interpre- 

l     tations. 

character  of:    melancholy  ideas,   persecutory 

ideas,  etc. 

n       ,   ,  •  f  incoherent  delirium. 

Correlations:  ,         ,.     ,   -.  r  . 

1  systematized  delirium. 

Degree  of  accuracy  of  systematization. 

'  changeable  delusions. 


Delusions. 


Reactions 


fixed  delusions. 
Evolution:      \  more  or  less  rapid  progress  of 
systematization. 
-disappearance  (convalescence). 
_  Relation  to  hallucinations. 

rparalyzed  (stupor). 
Intensity  \  weakened. 

[exaggerated  (impulsiveness). 


Origin 


emotional:  passionate  impulses. 


exclusively 
tomatic : 


r  simple  impulses. 
"  \  stereotypy. 


Conse- 
quences 


hallucinatory, 
delusional. 

reactions  of  de- 
fense 


I  negativism. 


means  of  defense 
(breastplates,  etc.). 

mystic  procedures  (in- 
cantations, etc.). 


aggres- 
sive ten- 
dencies 


'  towards 
others 

towards 
self 


towards  in- 
animate 
objects 


/  legal  procedures. 
\  assaults. 

{ suicide. 

I  self -mutilation. 

destruction  of 
furniture, 
breaking  of 
window-panes 
incendiarism, 
etc. 


APPENDIX. 


343 


'  rapid  or  slow,  hesitation. 


" spoken 


Language. 


tone 


,  voice 


monotonous: 
declamatory. 

•j  affected. 

|  supplicating. 

I  threatening. 

/  loud. 

1  inaudible. 


written. 


rapid  or  slow, 
peculiarly  shaped  letters, 
orthographical  errors. 


'  restricted  vocabulary, 
profanity, 
content  (spoken  1  affectation. 


and  written) 


reiterations. 

stereotypy. 

neologisms. 


r  absence, 
mimic \  exaggeration. 

I  affectation. 

(c)  Physical  Condition. 

f  anaesthesia. 
r  Sensibility    \  hyperesthesia. 
I  paresthesia. 


Principal  nervous 
diiturbances. 


Reflexes.  .  .  \ 


{ tendon, 
cutaneous. 


i  mucous. 
I-  pupillary. 


|  exaggerated. 
\  diminished. 


i  abolished. 


Motility 


r  weakness. 

\  incoordination. 

I  absence  of  the  sense  of  fatigue. 


Trophic  disorders. 


f  absent. 


Sleep 


d 


lmim 


shed. 


permanent  somolence. 
I  disturbed  bv  nightmares. 


344  APPENDIX. 

Great  organic  functions  [digestion,  circulation,  respiration,  ex- 
cretion, etc.]. 

General  nutrition. 

Anatomical  stigmata  of  degeneration. 


INDEX. 


Aboulia,  91 

Abscess  of  the  brain,  250 

Absinth,  150 

Affective  melancholia,  256 

Affectivity,  disorders  of,  79 

Age,  6,  205,  240,  256,  261,  287 

Agitation,  153,  257 

Agoraphobia,  309 

Akoasms,  44 

Alcohol,  19,  149,  243,  291 

Alcoholic  epilepsy,  151 

Alcoholic  systematized  delirium, 

159 
Alcoholism,  acute,  138 

—  chronic,  142 

—  etiology  of,  147 

—  treatment  of,  150 
Amnesia,  59 

—  anterograde,  59 

—  course  of,  61 

—  general,  63 

—  law  of,  61 

—  of  conservation,  60 

—  of  fixation,  59 

—  of  reproduction,  61 

—  partial,  62 

—  progressive,  61 

—  retrograde,  59 

—  retrogressive,  61 

—  stationary,  61 


Anamnesis,  99 
Anger,  87 
Anxiety,  84 

Apoplectiform  seizures  in  gen- 
eral paresis.  228 
Apoplexy,  250 
Arithmomania,  307 
Arrests  of  development,  327 

—  etiology  of,  327 

—  prognosis,      diagnosis,      and 

treatment  of,  333 
Arteriosclerosis,  250 
Associations  of  ideas,  65 
Attention,  65 

—  abnormal  mobility  of,  66 

—  enfeeblement  of,  65 
Auricle,  deformities  of,  301 
Autochthonous  ideas,  69 
Autointoxication,   19,  173,   180, 

206,  248 
Automatic  reactions,  91 
Automatism,  epileptic,  314 

—  mental,  65 

Baths,  cold,  111 

—  prolonged  warm,  111 
Bed-sores,  226 
Brachycephaly,  300 
Bright's  disease,  21,  174 
Bromides,  in  excitement,  113 

345 


346 


INDEX. 


Bromides,  in  epilepsy,  319 

—  in  manic  depressive  insanity, 

291 

Cachexia  of  general  paresis,  220 

—  of  morphinism,  168 

—  senile.  266 
Cancer,  19 
Catatonia,  193 
Catatonic  excitement,  194 
Catatonic  stupor,  195 
Causes  of  insanity,  1 

—  determining,  13 

—  general,  3 

—  individual,  8 

—  moral,  15 

—  physical,  14 

—  predisposing,  2 
Celibacy,  6 

Cerebral  softening,  250 
Cerebral  syphilis,  252 
Cerebral  tumors,  251 
Certificate  of  lunacy,  106 
Childbirth.  23,  206 
Chloral,  112 
Chloralose,  113 
Cholera,  135 

Chorea,  25 

Circular  insanity,  285 

Circulation,  changes  of, 

—  in  anger,  87 

—  in  depression ,  82 

—  in  euphoria,  89 

■ —  in  involution  melancholia, 258 

—  in  manic  depressive  insanity, 

273,  276,  279 
Civilization,  5,  246 
Classification  of  insanity,  121 
Claustrophobia,  310 
Climate,  3 
Clouding  of   consciousness,   55, 

129 


Cocaine  delirium,  171 
Cocainomania,  170 
Ccenesthesia,  95 
Cold  packs,  111 
Commitment,  105 
Confusional  insanity,  129 
Congenital  predisposition,  8 
Consanguinity,  10 
Consciousness,  55 

—  clouding  of,  55,  129 

—  exaggeration  of,  58 

—  loss  of,  55 

Constitutional  psychopaths,  298 
Contagion  of  insanity,  27,  296 
Convulsive  tendency,  11 
Cranial  deformities,  300 
Cretinism,  183 

Dangerous  patients,  106 
Degeneration,  acquired,  12 

—  congenital,  8 

—  hereditary,  9 

—  pathogenesis  of,  12 

—  physical  signs  of,  300 
Delire  a  deux,  27 
Delirium,  acute,  133 

— -  alcoholic  systematized,  159 

—  chronic,  207 

—  febrile,  125 

—  hallucinatory,  41 

—  incoherent,  72 

—  infectious,  126 

—  initial,  126 

—  melancholy,  75 

—  persecutory,  77 

—  retrospective,  72 

—  senile,  266 

—  systematized,  72 

—  transitory,  317 

—  tremens,  152 

—  unrmic,  173 
Delusions,  71 


INDEX. 


347 


Dementia,  ix 

—  alcoholic,  144 

—  epileptic,  312 

—  juvenile,  186 

—  paretic,  214 

—  senile,  261 
Dementia  praecox,  186 

—  catatonic  form,  193 

—  common  symptoms,  188 

—  course,  204 

—  delusional  forms,  198 

—  diagnosis,  202 

—  etiology,  205 

—  prognosis,  204 

—  simple  form,  192 

—  .somatic  disorders  in,  190 

—  treatment,  206 
Dental  caries,  22 
Dentition,  anomalies  of,  301 
Depression,  active,  84 

—  delusional,  280 

—  passive,  82 

—  simple,  277 

—  stuporous,  280 
Diabetes;  20 
Dipsomania,  307 
Disorientation,  55 
Dissimulation,  104 
Dolichocephaly,  300 
Doubt,  insanity -of,  309 
Douche,  111 
Dream-delirium,  72 

Dreams  of   chronic  alcoholism, 

144 
Drunkenness,  comatose,  139 

—  common,  138 

—  convulsive,  140 

—  delusional,  141 

—  maniacal,  140 

—  pathological,  138 

Echo  of  the  thought,  45 


Echolalia,  92 
Echopraxia,  92 
Ecstasy,  88 
Emotions,  26,  79 
Epilepsy,  311 

—  paroxysmal  mental  disorders 

of,  313 

—  permanent  mental  disorders 

of,  311 

—  responsibility  in,  320 

—  treatment  of,  318 
Epileptic  absences,  313 

—  automatism,  314 

—  character,  311 

—  delirium,  314 

—  vertigo,  313 
Epileptiform  seizures  in  general 

paresis,  228 
Eroticism,  301 
Eruptive  fevers,  16 
Erythrophobia,  310 
Ether,  169 

Etiology  of  insanity,  1 
Euphoria,  88 

Examination  of  patients,  100 
Excitement,  catatonic,  194 

—  maniacal,  269 

—  of  paresis,  230 

—  -treatment  of,  109 
Exhaustion  psychoses,  129 
Exhibitionism,  263,  303 
Exophthalmic  goitre,  25 

Fabrications,  see  Imaginary 
recollections,  also  Hallu- 
cinations of  memory. 

Family  history,  99 

Febrile  delirium   125 

Feeble-mindedness,  329 

Fetichism,  302 

Fixed  ideas,  69,  292 

Flight  of  ideas,  66,  132,  268 


348 


INDEX. 


Food,  refusal  of,  117 
Forced  feeding,  118 
Frigidity,  301 
Furor,  88,  315 

General  paresis,  211 

—  course,  232 

—  diagnosis,  232 

—  essential  symptoms,  214 

—  etiology,  240 

—  forms,  229 

—  inconstant  symptoms,  221 

—  pathology,  235 

—  prodromata,  212 

—  prognosis,  232 

—  treatment,  248 
Genital  anomalies,  301 
Glycosuria,  21 
Goitre,  184 
Gonorrhoea,  16 
Gout,  20 

Hematoma  auris,  225 
Hallucinations,  32 

—  auditory,  43,  160,   198,  208, 

265 

—  by  suggestion,  43 

—  combined,  38 

—  conscious,  34 

—  definitions  of,  32 

—  diagnosis  of,  39 

—  etiology  of,  41 

—  hypnagogic,  41 

—  indifferent,  36 

—  induced,  43 

—  motor,  49 

—  motor  graphic,  51 

—  motor  verbal,  50 

—  of  general  sensibility,  49 

—  of  memory,  63 

—  of  smell,  48 

—  of  taste,  48 


Hallucinations,   of    the    genital 
sense,  49 

—  of  touch,  49 

—  peripheral,  42 

—  pleasing,  36 

—  properties  of,  33 

—  psychic,  70 

—  reflex,  42 

—  theories  of,  52 

—  unilateral,  42 

—  unpleasant  or  painful,  36 

—  visual,  46 
Handwriting,  102,  218 
Harelip,  300 

Heart  disease,  22 
Hebephrenia,  187* 
Hemorrhage,  23,  25,  135 

—  cerebral,  250 

Heredity,  8,  147,  205,  241,  256, 
261,  286,  310,  327 

—  forms  of,  9 
Homicidal  obsession,  307 
Hydrophobia,  mental  disorders 

of,  127 
Hydrotherapy,  111 
Hyperconsciousness;  58 
Hypnotism,  310,  326 
Hysteria,  321 

—  episodic  mental  disorders,  323 

—  permanent  mental  disorders, 

321 

—  treatment,  326 
Hysterical  lying,  323 

Ideas,  associations  of,  65 

—  autochthonous,  69 

—  fixed,.  69,  292 

—  flight  of,  66,  132,  268 

—  imperative,  69 

—  incoherence  of,  68,  189,  260 

—  melancholy,  73,  198,  201,  231, 

259,  265,  280 


INDEX. 


340 


Ideas,  metaphysical,  74 

—  of  culpability,  73 

—  of  enormity,  74 

—  of    grandeur,    78,    173     199, 

201,   209,     230,   266,    274, 
292 

—  of  humility,  73 

—  of  immortality,  74 

—  of  jealousy,  161 

—  of  negation,  74 

—  of  persecution,  76,  153,  160, 

173,  200,  208,  229,  265,  292 

—  of  possesion,  75 

—  of  ruin,  73 

—  of  self-accusation,  73 

—  subconscious,  69,  322 
Idiocy,  328 

Illegitimate  children,  6 
Illusions,  31 

Imaginary  recollections,  64,  177 
Imbecility,  328 
Imperative  ideas,  69 
Impulse,  conscious,  93 

—  passionate,  92 

—  simple,  92 
Inanition,  21 
Incoherence,  68,  189,  260 
Increase  of  insanity,  5 
Indifference,  79,  189 
Infections,  acute,  16 

—  chronic,  17 
Infectious  deliria,  124 
Influenza,  16 
Insanity,  alternating,  285 

—  circular,  285 

—  manic  depressive,  268 

—  moral,  333 

—  of  double  form,  283 

—  of  doubt,  308 

—  periodic  or  recurrent,  284 

—  reasoning,  292 
- —  reflex,  23 


Interpretations,    false    or   delu- 
sional, 72 
Intoxications,  19 
Inversion,  sexual,  304 
Isolation,  112 

—  in  prison  cells,  27 

Jealousy    delirium,  in    chronic 
alcoholism,  161 

—  in  paranoia,  296 
Joy,  88 
Judgment,  71 

Kidney  lesions,  21 
Kleptomania,  307 
Korsakoff's  disease,  175 

Lactation,  24 
Law  of  amnesia,  61 
Lead  poisoning,  19,  235 
Lisping  speech,  330 
Litigious  paranoiacs,  296 
Liver  troubles,  22 
Logorrhea,.  of  mania,  273 
— -  of  melancholia,  283 
Lumbar  puncture,  233 
Lying,  hysterical,  323 
Lypemania,  see  Melancholia. 

Macrocephaly,  300 

Malaria,  16 

Mania,  confused,  275 

—  delusional,  273 

—  recurrent,  284 

—  simple,  269 

Manic  depressive  insanity,  268 

—  course,  284 

—  diagnosis,  287 

—  etiology,  286 

—  homogeneity  of,  287 

—  mixed  types  of,  282 

—  prognosis,  286 

—  treatment,  277,  282,  291 


350 


INDEX. 


Manic  depressive  insanity,  types 

of,  268 
Marriage,  6 
Masochism,  304 
Masturbation,  302 
Mechanical  restraint,  109 
Medication  in  excitement,  112 
Medico-legal  testimony,  107 
Melancholia  of  involution,  256 

—  agitated,  257 

—  anxious,  257 

—  delusional,  258 

—  stuporous,  257 
Melancholic  wasting,  260 
Memory,  59 

—  disorders  of,  59 

—  illusions    and    hallucinations 

of,  63,  176 
Menopause,  7,  240 
Menstruation,  23 
Mental  alienation,  xi 
Mental  automatism,  65 
Mental  diseases,  x 
Mercury,  19 
Metaphysical  ideas,  74 
Microcephaly,  300 
Monomania,  see  Paranoia. 
Moral    factors    in    the    etiology 

of  insanity,  26 
Moral  insanity,  333 
Moral  pain,  84,  256 
Morbid  anger,  87 

—  depression,  81 

—  euphoria  or  joy,  88 

—  indifference,  79 

—  irritability,  80 

—  religious  fanaticism,  311 
Morphinomania,  163 

—  causes,  163 

—  evolution,  165 

—  symptoms  of  abstinence  in, 

167 


Morphinomaina,  treatment,  169 
Mystics,  296 
Myxcedema,  180 

Negativism,  93,  196 
Negroes,  insanity  in,  3,  5 
Neologisms,  46,  200 
Neuralgia,  26 
Neurasthenia,  25,  137 
Neuroses,  25 
Nosophobia,  309 
Notion  of  personality,  55,  95 

—  of  the  external  world,  55 

—  of  time,  55 

Obsessions,  305 

—  homicidal,  307 

—  impulsive,  307 

—  inhibiting,  308 

—  intellectual,  306 

—  suicidal,  307 
Occupation-delirium,  153 
Occupation-dreams,  144 
Occupation,  in  the  etiology  of 

insanity,  7 
Onanism,  302 
Onomatomania,  307 
Opium,  in  excitement,  112 

—  in  affective  melancholia,  260 

—  in  epilepsy,  319 

Organic  cerebral  affections,  250 
Orientation,  allopsychic,  55 

—  autopsychic,  55 

—  of  time,  55 
Overwork,  21,  243 

Paralysis  agitans,  25 
Paranoia,  292 

—  originaire,  293 

—  querulens,  296 
Paranoid  dementia,  199 


INDEX. 


351 


Paroxysmal  mental  puerilism,  97 
Pathological  drunkenness,  138 
Pathological   suggestibility,   91, 

197,  264,  323,  330 
Pellagra,  19 
Perception,  disorders  of,  29 

—  imaginary,  32 

—  inaccurate,  31 

—  insufficiency  of,  30 
Persecutory  delirium,  77 
Personal  history,  99 
Personality,  disorders  of,  95 

—  reduplication  of,  97 

—  transformation  of,  96 
Phobias,  309 
Phonemes,  44 
Phosphorus,  7 
Plumbism,  19,  235 
Polyneuritic  psychosis,  175 

—  course,  178 

—  etiology,  175 

—  diagnosis,  179 

—  prognosis,  178 

—  symptoms,  176 

—  treatment,  179 
Post-operative  psychoses,  25 
Predisposition,  acquired,  12 

—  congenital,  8 

—  hereditary,  9 
Pregnancy,  24,  206 

Presenile  paranoic  condition,  or 
presenile  persecutory  delir- 
ium, 265 

Pseudo-paresis,  235 

Psychic  interference,  94 

Psychopaths,  constitutional,  29S 

Psychoses,  x 

Puerperium,  23,  206 

Pupillary  disorders  in  dementia 
prsecox,  191 

—  in  general  paresis,  219 
Pyromania,  307 


Race,  3,  246 
Reactions,  90 

—  voluntary,  90 

—  automatic,  91 
Reading  test,  102 
Refusal  of  food,  117 
Religious  scruples,  309 
Remissions  in  dementia  prsecox, 

204 

—  in  general  paresis,  232 
Respiratory  changes,  in  anger,  87 

—  in  euphoria  or  joy,  88 

—  in  depression,  83 
Responsibility,  108 

—  in  epilepsy,  320 
Rest  in  bed,  110 
Restraint,  309 
Reticence,  104 
Rheumatism,  16 

Sadism,  303 

Saturnine  encephalopathy,  235 
Scanning  speech,  218 
Scaphocephaly,  300 
Seasons,  4 
Se junction,  54 
Self-mutilation,  117 
Senile  dementia,  261 

—  course,  266 
— ■  diagnosis,  267 

—  etiology,  261 

—  prognosis,  266 

—  symptoms,  262 

—  treatment,  267 
Septicaemia,  16 
Sex,  8,  240 

Sexual  inversion,  304 
Sexual  perversion,  302 
Simulation  of  insanity,  103 
Sitiophobia,  117 

Social  factors   in  the  causation 
of  insanity,  5f  14S 


352 


INDEX. 


Softening  of  the  brain,  250 
Speech  disturbances  in  general 
paresis,  217 

—  in  idiocy  and  imbecility,  330 
Spinal-cord   lesions    in    general 

paresis,  237 
Stammering,  330 
States  of  obscuration,  57 
Stealing  of  thoughts,  46 
Stereotypy,  93,  196,  216 
Stomach  disorders,  22 
Stupor  in  primary  mental  con- 
fusion, 133 

—  in  affective  melancholia,  257 

—  in  catatonia,  195 

—  in  manic  depressive  insanity, 

280,  283 
■ —  post-epileptic,  314,  316 
Stuttering,  330 
Suggestibility,  91,  197,  264,  323, 

330 
Suggestion,  310,  326 
Suicidal  tendencies,  115 
Symptoms     of     abstinence     in 

morphinomania,  167 
Syndrome  of  Cotard,  75,  201,  259 
Syphilis,  17,  244,  252 


Systematized  delirium,  72 

Tabes,  25 

Tabetic  form  of  general  paresis, 
231 

Tattooing,  301 

Testimony  of  idiots  and  imbe- 
ciles, 330 

Thyroid  gland,  181,  184 

Traumatisms  in  the  etiology  of 
insanity,  24,  243 

Tremors,  145,  216 

Tuberculosis,  17 

Tumor  of  the  brain,  251 

Twin  births,  11 

Typhoid  fever,  16 

Uremic  delirium,  173 
Unbalanced  individuals,  299 

Verbigeration,  93 
Visions,  46 

Wasting  in  melancholia,  260 
Wet  packs,  111 
Writing  test,  102 

Zoopsia,  144 


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*  Phelps's  Practical  Marine  Surveying 8vo, 

Powell's  Army  Officer's  Examiner i2mo, 

Sharpe's  Art  of  Subsisting  Armies  in  War i8mo,  morocco, 

*  Walke's  Lectures  on  Explosives 8vo, 

*  Wheeler's  Siege  Operations  and  Military  Mining 8vo, 

Winthrop's  Abridgment  of  Military  Law i2mu, 

Woodhull's  Notes  on  MiUtary  Hygiene 1 6010, 

Young's  Simple  Elements  of  Navigation i6mo  morocco, 

Second  Edition,  Enlarged  and  Revised i6mo,  morocco, 

ASSAYING. 

Fletcher's  Practical  Instructions  in  Quantitative  Assaying  with  the  Blowpipe. 

i2mo,  morocco, 

Furman's  Manual  of  Practical  Assaying 8vo, 

Lodge's  Notes  on  Assaying  and  Metallurgical  Laboratory  Experiments.  .  .  .8vo, 

Miller's  Manual  of  Assaying i2mo, 

O'Driscoll's  Notes  on  the  Treatment  of  Gold  Ores 8vo, 

Ricketts  and  Miller's  Notes  on  Assaying 8vo, 

Ulke's  Modern  Electrolytic  Copper  Refining 8vo, 

Wilson's  Cyanide  Processes 12010, 

Chlorination  Process i2mo, 

ASTRONOMY. 

Comstock's  Field  Astronomy  for  Engineers 8vo, 

Craig's  Azimuth 4to, 

Doolittle's  Treatise  on  Practical  Astronomy 8vo, 

Gore's  Elements  of  Geodesy 8vo, 

Hayford's  Text-book  of  Geodetic  Astronomy 8vo, 

Merriman's  Elements  of  Precise  Surveying  and  Geodesy 8vo, 

*  Michie  and  Harlow's  Practical  Astronomy 8vo, 

*  White's  Elements  of  Theoretical  and  Descriptive  Astronomy i2mo, 

BOTANY. 

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i6mo,  morocco,  1  25 

Thomd  and  Bennett's  Structural  and  Physiological  Botany ;6mo,  2  25 

Westermaier's  Compendium  of  General  Botany.     (Schneider.) 8vo.  2  00 

CHEMISTRY. 

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Brush  and  Penfield's  Manual  of  Determinative  Mineralogy 8vo- 

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Tests  and  Reagents 8vo, 

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Ende) lamo, 

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Eissler's  Modern  High  Explosives 8vo, 

Effront's  Enzymes  and  their  Applications.     (Prescott.). 8vo, 

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Erdmann's  Introduction  to  Chemical  Preparations.     (Duniap.) i2mo,    1  25 

Fletcher's  Practical  Instructions  in  Quantitative  Assaying  with  the  Blowpipe 

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Fowler's  Sewage  Works  Analyses i2mo, 

Fresenius's  Manual  of  Qualitative  Chemical  Analysis.     (Wells.) 8vo, 

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System   of  Instruction   in    Quantitative    Chemical   Analysis.      (Cohn.) 

2  vols . 8vo, 

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Getman's  Exercises  in  Physical  Chemistry i2mo, 

Gill's  Gas  and  Fuel  Analysis  for  Engineers i2mo, 

Grotenfelt's  Principles  of  Modern  Dairy  Practice.     (WolL) i2mo. 

Hammarsten's  Text-book  of  Physiological  Chemistry.     (MandeL) 8vo, 

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*  Reisig's  Guide  to  Piece-dyeing 8vo,  25  00 

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French  and  Ives's  Stereotomy 8vo, 

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Howe's  Retaining  Walls  for  Earth .      nmo,  i  25 

Johnsons  (J.  B.)  Theory  and  Practice  01  Surveying Small  8vo,  4  00 

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Sabin's  Industrial  and  Artistic  Technology  of  Paints  and  Varnish 8vo, 

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Dawson's  "Engineering"  and  Electric  Traction  Pocket-book.     i6mo,  morocco,  5  00 

Dredge's  History  of  the  Pennsylvania  Railroad:  (1879) Paper,  5  00 

*  Drinker's  Tunneling,  Explosive  Compounds,  and  Rock  Drills,  4to,.half  mor.,  25  00 

Fisher's  Table  of  Cubic  Yards Cardboard,  25 

Godwin's  Railroad  Engineers'  Field-book  and  Explorers'  Guide ....  i6mo,  mor.,  2  50 

Howard's  Transition  Curve  Field-book. i6mo,  morocco,  *  1  50 

Hudson's  Tables  for  Calculating  the  Cubic  Contents  of  Excavations  and  Em- 
bankments  8vo,  1  00 

Molitor  and  Beard's  Manual  for  Resident  Engineers i6mo,  1  00 

Nagle's  Field  Manual  for  Railroad  Engineers i6mo,  morocco,  3  -oo 

Philbrick's  Field  Manual  for  Engineers i6mo,  morocco,  3  00 

Searles's  Field  Engineering i6mo,  morocco,  3  -oo 

Railroad  Spiral i6mo,  morocco,  1  50 

Taylor's  Prismoidal  Formula?  and  Earthwork 8vo,  1  50 

*  Trautwine's  Method  ot  Calculating  the  Cubic  Contents  of  Excavations  and 

Embankments  by  the  Aid  of  Diagrams 8vo,  2  00 

The  Field  Practice  of  Laying  Out  Circular  Curves  for  Railroads. 

i2mo„  morocco, 

Cross-section  Sheet Paper, 

Webb's  Railroad  Construction.     2d  Edition,  Rewritten i6mo,  morocco, 

Wellington's  Economic  Theory*  of  the  Location  of  Railways Small  8vo, 

DRAWING. 
Barr's  Kinematics  of  Machinery 8vo, 

*  Bartlett's  Mechanical  Drawing 8vo, 

*  "       Abridged  Ed 8vo, 

Coolidge's  Manual  ot  Drawing 8vo,  paper, 

Coolidge  and  Freeman's  Elements  of  General  Drafting  for  Mechanical  Engi- 
neers  Oblong  4to. 

Durley's  Kinematics  of  Machines 8vo, 

Emch's  Introduction  to  Projective  Geometry  and  its  Applications 8vo, 

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Hill's  Text-book  on  Shades  and  Shadows,  and  Perspective 8vo, 

Jamison's  Elements  of  Mechanical  Drawing 8vo, 

Jones's  Machine  Design: 

Part  I. — Kinematics  of  Machinery 8vo, 

Part  II. — Form,  Strength,  and  Proportions  of  Parts 8vo, 

MacCord's  Elements  of  Descriptive  Geometry 8vo, 

Kinematics;  or,  Practical  Mechanism 8vo, 

Mechanical  Drawing 4to, 

Velocity  Diagrams 8vo, 

Mahan's  Descriptive  Geometry  and  Stone-cutting 8vo, 

Industrial  Drawing.     (Thompson.) 8vo, 

Moyer's  Descriptive  Geometry.     (In  press.) 

Reed's  Topographical  Drawing  and  Sketching 4to, 

Reid's  Course  in  Mechanical  Drawing 8vo, 

Text-book  of  Mechanical  Drawing  and  Elementary  Machine  Design.  .8vo, 

Robinson's  Principles  of  Mechanism 8vo, 

Schwamb  and  Merrill's  Elements  of  Mechanism 8vo, 

Smith's  Manual  of  Topographical  Drawing.     (McMillan.) 8vo, 

Warren's  Elements  of  Plane  and  Solid  Free-hand  Geometrical  Drawing .  .  i2mo, 

Drafting  Instruments  and  Operations nmo, 

Manual  of  'Elementary  Projection  Drawing nmoj 

Manual  of  Elementary  Problems  in  the  Linear  Perspective  of  Form  and 
Shadow i2mo, 

Plane  Problems  in  Elementary  Geometry i2mo, 

Primary  Geometry nmo, 

Elements  of  Descriptive  Geometry,  Shadows,  and  Perspective 8vo, 

General  Problems  of  Shades  and  Shadows 8vo, 

Elements  of  Machine  Construction  and  Drawing 8vo, 

Problems,  Theorems,  and  Examples  in  Descriptive  Geometry 8vo, 

Weisbach's   Kinematics   and   the   Power   of   Transmission.     (Hermann   and 
Klein.) 8vo, 

Whelpley's  Practical  Instruction  in  the  Art  of  Letter  Engraving nmo, 

Wilson's  (H.  M.)  Topographic  Surveying 8vo, 

Wilson's  (V.  T.)  Free-hand  Perspective 8vo, 

Wilson's  (V.  T.)  Free-hand  Lettering 8vo, 

Woolf 's  Elementary  Course  in  Descriptive  Geometry Large  8vo , 

ELECTRICITY  AND   PHYSICS. 

Anthony  and  Brackett's  Text-book  of  Physics.     (Magie.) Small  8vo, 

Anthony's  Lecture-notes  on  the  Theory  of  Electrical  Measurements.  .  .  .  nmo, 

Benjamin's  History  of  Electricity 8vo, 

Voltaic  Cell 8vo, 

Classen's  Quantitative  Chemical  Analysis  by  Electrolysis.     (Boltwood.).  .  8vo, 

Crehore  and  Squier's  Polarizing  Photo-chronograph 8vo, 

Dawson's  "Engineering"  and  Electric  Traction  Pocket-book.  .  i6mo,  morocco, 
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Ende.) nmo, 

Duhem's  Thermodynamics  and  Chemistry.     (Burgess.) 8vo, 

Flather's  Dynamometers,  and  the  Measurement  of  Power nmo, 

Gilbert's  De  Magnete.     (Mottelay.) 8vo, 

Hanchett's  Alternating  Currents  Explained nmo, 

Hering's  Ready  Reference  Tables  (Conversion  Factors) i6mo,  morocco, 

Holman's  Precision  of  Measurements 8vo, 

Telescopic  Mirror-scale  Method,  Adjustments,  and  Tests Large  8vo, 

Kinzbrunner's  Testing  of  Continuous-Current  Machines 8vo, 

Landauer's  Spectrum  Analysis.    (Tingle.) 8vo, 

Le  Chatelier's  High-temperature  Measurements.  (Boudouard — Burgess.  )i2mo. 
Lob's  Electrolysis  and  Electrosynthesis  of  Organic  Compounds.  (Lorenz.)  nmo, 

9 


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SO 

*  Lyons's  Treatise  on  Electromagnetic  Phenomena.    Vols.  I.  and  II.  8vo,  each, 

*  Michie.     Elements  of  Wave  Motion  Relating  to  Sound  and  Light 8vo, 

Niaudet's  Elementary  Treatise  on  Electric  Batteries.     (FishDack. ) nmo, 

*  Rosenberg's  Electrical  Engineering.   (Haldane  Gee — Kinzbrunner.) . . .  .8vo, 

Ryan,  Ncrris,  and  Eoxie's  Electrical  Machinery.     Vol.  L 8vo, 

Thurston's  Stationary  Steam-engines 8vo, 

*  Tillman's  Elementary  Lessons  in  Heat 8vo, 

Tory  and  Pitcher's  Manual  of  Laboratory  Physics Small  8vo. 

Ulke'js  Modern  Electrolytic  Copper  Refining 8vo, 

LAW. 

*  Davis's  Elements  of  Law 8vo, 

*  Treatise  on  the  Military  Law  ot  United  States .8vo, 

*  Sheep, 

Manual  for  Courts-martial i6mo,  morocco, 

Wait's  Engineering  and  Architectural  Jurisprudence 8vo, 

Sheep, 

Law  of  Operations  Preliminary  to  Construction  in  Engineering  and  Archi- 
tecture     8vo, 

Sheep, 

Law  of  Contracts 8vo, 

Winthrop's  Abridgment  of  Military  Law i2mo, 

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Molecule i2mo, 

Bolland's  Iron  Founder i2mo, 

•'  The  Iron  Founder,*'  Supplement. i2mo, 

Encyclopedia  of  Founding  and  Dictionary  of  Foundry  Terms  Used  in  the 

Practice  of  Moulding nmo, 

Eissler's  Modern  High  Explosives 8vo, 

Effront's  Enzymes  and  their  Applications.     (Prescott.) 8vo 

Fitzgerald's  Boston  Machinist i8mo, 

Ford's  Boiler  Making  for  Boiler  Makers i8mo, 

Hopkins's  Oil-chemists'  Handbook. „ . 8vo, 

Keep's  Cast  Iron 8vo, 

Leach's  The  Inspection  and  Analysis  of  Food  with  Special  Reference  to  State 

Control.     (In  preparation.) 

Matthews's  The  Textile  Fibres 8vo, 

Metcalf's  SteeL     A  Manual  for  Steel-users i2mo, 

Metcalfe's  Cost  of  Manufactures — And  the  Administration    of  Workshops, 

Public  and  Private 8vo, 

Meyer's  Modern  Locomotive  Construction 4*0, 

Morse's  Calculations  used  in  Cane-sugar  Factories i6mo,  moroccc, 

*  Reisig's  Guide  to  Piece-dyeing .8vo, 

Sabin's  Industrial  and  Artistic  Technology  of  Paints  and  Varnish 8vo, 

Smith's  Press-working  of  Metals 8vo, 

Spalding's  Hydraulic  Cement nmo, 

Spencer's  Handbook  for  Chemists  of  Beet-sugar  Houses i6mo,  morocco, 

Handbook  for  Sugar  Manufacturers  and  their  Chemists.. .  i6mo  morocco, 
Taylor  and  Thompson's  Treatise  on  Concrete,  Plain  and  Reinforced.     (In 

press.) 
Thurston's  Manual  of  Steam-boilers,  their  Designs,  Construction  and  Opera- 
tion   8vo,    5  00 

*  Walke'3  Lectures  on  Explosives 8vo,    4  00 

West's  American  Foundry  Practice i2mo,    2  50 

Moulder's  Text-book i2mo,    2  50 

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2 

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Wolff '8  Windmill  as  a  Prime  Mover 8vo,  3  00 

Woodbury's  Fire  Protection  of  Mills 8vo,  2  50 

Wood's  Rustless  Coatings:  Corrosion  and  Electrolysis  of  Iron  and  Steel.  .  .8vo,  4  00 

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Baker's  Elliptic  Functions 8vo,  1  50 

*  Bass's  Elements  of  Differential  Calculus i2mo,  4  00 

Briggs's  Elements  of  Plane  Analytic  Geometry i2mo,  1  00 

Compton's  Manual  of  Logarithmic  Computations nmo,  1  50 

Davis's  Introduction  to  the  Logic  of  Algebra 8vo,  1  50 

*  Dickson's  College  Algebra Large  nmo,  1  50 

*  Introduction  to  the  Theory  of  Algebraic  Equations   Large  nmo,  1   25 

Emch's  Introduction  to  Projective  Geometry  and  its  Applications 8vo,  2  50 

Halsted's  Elements  of  Geometry 8vo,  1   75 

Elementary  Synthetic  Geometry 8vo,  1  50 

Rational  Geometry nmo, 

*  Johnson's  (J.  B.)  Three-place  Logarithmic  Tables:  Vest-pocket  size,  .paper,  15 

100  copies  for  5  00 

*  Mounted  on  heavy  cardboard,  8X10  inches,  25 

10  copies  for  2  00 

Johnson's  (W.  W.)  Elementary  Treatise  on  Differential  Calculus.  .    Small  8vo,  3  00 

Johnson's  (W.  W.)  Elementary  Treatise  on  the  Integral  Calculus.  .Small  8vo,  1   50 

Johnson's  (W.  W.)  Curve  Tracing  in  Cartesian  Co-ordinates nmo,  1  00 

Johnson's  (W.  W.)  Treatise  on  Ordinary  and  Partial  Differential  Equations. 

Small  8vo,  3  50 

Johnson's  (W.  W.)  Theory  of  Errors  and  the  Method  of  Least  Squares.  .  i2mo,  1   50 

*  Johnson's  (W.  W.)  Theoretical  Mechanics nmo,  3  00 

Laplace's  Philosophical  Essay  on  Probabilities.     (Truscott  and  Emory.)  nmo,  2  00 

*  Ludlow  and  Bass.     Elements  of  Trigonometry  and  Logarithmic  and  Other 

Tables 8vo,  3  00 

Trigonometry  and  Tables  published  separately Each,  2  00 

*  Ludlow's  Logarithmic  and  Trigonometric  Tables 8vo,  1  00 

Maurer's  Technical  Mechanics 8vo,  4  00 

Merriman  and  Woodward's  Higher  Mathematics 8vo,  5  00 

Merriman's  Method  of  Least  Squares 8vo,  2  00 

Rice  and  Johnson's  Elementary  Treatise  on  the  Differential  Calculus .  Sm.,  8vo,  3  00 

Differential  and  Integral  Calculus.     2  vols,  in  one Small  8vo,  2  50 

Wood's  Elements  of  Co-ordinate  Geometry 8vo,  2  00 

Trigonometry:  Analytical,  Plane,  and  Spherical nmo,  1  00 

MECHANICAL   ENGINEERING. 

MATERIALS  OF  ENGINEERING,  STEAM-ENGINES  AND  BOILERS. 

Bacon's  Forge  Practice nmo,  1  50 

Baldwin's  Steam  Heating  for  Buildings. nmo,  2  50 

Barr's  Kinematics  of  Machinery. 8vo,  2  50 

*  Bartlett's  Mechanical  Drawing 8vo,  3  00 

*  "                 H               -        Abridged  Ed 8vo,  1  50 

Benjamin's  Wrinkles  and  Recipes nmo,  2  00 

Carpenter's  Experimental  Engineering .s 8vo,  6  00 

Heating  and  Ventilating  Buildings 8vo,  4  00 

Cary's  Smoke  Suppression  in  Plants  using  Bituminous  CoaL      (In  prep- 
aration.) 

Clerk's  Gas  and  Oil  Engine Small  8vo,  4  00 

Coolidge's  Manual  of  Drawing 8vo,    paper,  1  00 

Coolidge  and  Freeman's  Elements  of  General  Drafting  for  Mechanical  En- 
gineers  Oblong  4to,  2  50 

11 


Cromwell's  Treatise  on  Toothed  Gearing nmo 

Treatise  on  Belts  and  Pulleys nmo, 

Durley's  Kinematics  of  Machines 8vo, 

Flather's  Dynamometers  and  the  Measurement  of  Power i2mo, 

Rope  Driving i2mo. 

Gill's  Gas  and  Fuel  Analysis  for  Engineers nmo, 

Hall's  Car  Lubrication i2mo, 

Hering's  Ready  Reference  Tables  (Conversion  Factors) i6mo,  morocco, 

Hutton's  The  Gas  Engine 8vo, 

Jamison's  Mechanical  Drawing 8vo, 

Jones's  Machine  Design: 

Part  I. — Kinematics  of  Machinery 8vo, 

Part  IL — Form,  Strength,  and  Proportions  of  Parts 8vo, 

Kent's  Mechanical  Engineer's  Pocket-book i6mo,  morocco, 

Kerr's  Power  and  Power  Transmission 8vo, 

Leonard's  Machine  Shops,  Tools,  and  Methods.    (In  press.) 

MacCord's  Kinematics;  or,  Practical  Mechanism 8vo, 

Mechanical  Drawing 4to, 

Velocity  Diagrams 8vo, 

Mahan's  Industrial  Drawing.    (Thompson.) 8vo, 

Poole's  Calorific  Power  of  Fuels. . . . .' 8vo, 

Reid's  Course  in  Mechanical  Drawing 8vo, 

Text-book  of  Mechanical  Drawing  and  Elementary  Machine  Design.  .8vo, 

Richards's  Compressed  Air i2mo, 

Robinson's  Principles  of  Mechanism 8vo, 

Schwamb  and  Merrill's  Elements  of  Mechanfsm 8vo, 

Smith's  Press-working  of  Metals 8vo, 

Thurston's  Treatise  on   Friction  and    Lost  Work  in   Machinery   and  Mill 

Work 8vo, 

Animal  as  a  Machine  and  Prime  Motor,  and  the  Laws  of  Energetics,  nmo, 

Warren's  Elements  of  Machine  Construction  and  Drawing 870, 

Weisbach's  Kinematics  and  the  Power  of  Transmission.      Herrmann- 
Klein.)  8vo, 

Machinery  of  Transmission  and  Governors.     (Herrmann— Klein.).  .8vo, 

Hydraulics  and  Hydraulic  Motors.     (Du  Bois.) " 8vo> 

Wolff's  Windmill  as  a  Prime  Mover 8vo, 

Wood's  Turbines , . , , . 8vo, 

MATERIALS  OF  ENGINEERING. 

Bovey's  Strength  of  Materials  and  Theory  of  Structures 8vo,    7  50 

Burr's  Elasticity  and  Resistance  of  the  Materials  of  Engineering.     6th  Edition 

Reset 8vo, 

Church's  Mechanics  of  Engineering 8vo, 

Johnson'"  Materials  of  Construction Large  8vo, 

Keep's  Cast  Iron 8vo, 

Lanza's  Applied  Mechanics 8vo, 

Martens's  Handbook  on  Testing  Materials.     (Henning.) 8vo, 

Merriman's  Text-book  on  the  Mechanics  of  Materials .8vo, 

Strength  of  Materials    nmo, 

Metcalf's  SteeL     A  Manual  for  Steel-users nmo 

Sabin's  Industrial  and  Artistic  Technology  of  Paints  and  Varnish 8vo, 

Smith's  Materials  of  Machines nmo, 

Thurston's  Materials  of  Engineering ,".  .3  vols.,  Svo.    8  00 

Part   H. — Iron  and  Steel ; 8vo,    3  50 

Part  HI. — A  Treatise  on  Brasses,  Bronzes,  and  Other  Alloys  and  their 

Constituents 8vo     2  50 

Text-book  of  the  Materials  of  Construction 8vo,    5  00 

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Wood's  (De  V.)  Treatise  on  the  Resistance  of  Materials  and  an  Appendix  on 

the  Preservation  of  Timber 8vo,    2  00 

Wood's  (De  V.)  Elements  of  Analytical  Mechanics 8vo,    3  00 

Wood's  (M.  P.)  Rustless  Coatings:  Corrosion  and  Electrolysis  of  Iron  and  Steel. 

8vo,    4  00 


STEAM-ENGINES  AND  BOILERS. 

Carnot'8  Reflections  on  the  Motive  Power  of  He? t.     (Thurston.) i2rro,    1  50 

Dawson's  "Engineering"  and  Electric  Traction  Pocket-book.  .  i6mo,  mcr.,    5  00 

Ford's  Boiler  Making  for  Boiler  Makers i8mo,    1  00 

Goss's  Locomotive  Sparks 8vo,    2  00 

Hemenway's  Indicator  Practice  and  Steam-engine  Economy i2mo,    2  00 

Hutton's  Mechanical  Engineering  of  Power  Plants 8vo,    5  00 

Heat  and  Heat-engines .8vo,    5  co 

Kent's  Steam-boiler  Economy 8vo,    4  00 

Kneass's  Practice  and  Theory  of  the  Injector 8vo,    1  50 

MacCord's  Slide-valves 8vo,    2  00 

Meyer's  Modern  Locomotive  Construction 4to.    10  00 

Peabody's  Manual  of  the  Steam-engine  Indicator i2mo,    1  50 

Tables  of  the  Properties  of  Saturated  Steam  and  Other  Vapors 8vo,    1  00 

Thermodynamics  of  the  Steam-engine  and  Other  Heat-engines 8vo,    5  00 

Valve-gears  for  Steam-engines 8vo,    2  50 

Peabody  and  Miller's  Steam-boilers 8vo.   4  00 

Pray'a  Twenty  Years  with  the  Indicator Large  8vo,    2  50 

Pupln's  Thermodynamics  of  Reversible  Cycles  in  GaseB  and  Saturated  Vapors 

(Osterberg.) i2mo.   1   25 

Reagan's  Locomotives:  Simple,  Compound,  and  Electric t2mo.  2  50 

Rontgen's  Principles  of  Thermodynamics.     (Du  Bois.) Svo,    5  00 

Sinclair's  Locomotive  Engine  Running  and  Management i2mo,    2  00 

Smart's  Handbook  of  Engineering  Laboratory  Practice i2mo,    2  50 

Snow's  Steam-boiler  Practice 8vo,    3  00 

Spangler's  Valve-gears 8vo,    2  50 

Notes  on  Thermodynamics i2mo,    1  00 

Spangler,  Greene,  and  Marshall's  Elements  of  Steam-engineering 8vo,    3  00 

Thurston's  Handy  Tables 8vo,    1  50 

Manual  of  the  Steam-engine 2  vols.  8vo,  10  00 

Part  I. — History,  Structuce,  and  Theory 8vo,    6  00 

Part  H.— Design,  Construction,  and  Operation 8vo,    6  00 

Handbook  of  Engine  and  Boiler  Trials,  and  the  Use  of  the  Indicator  and 

the  Prony  Brake 8vo,  5  00 

Stationary  Steam-engines 8vo,  2  50 

Steam-boiler  Explosions  in  Theory  and  in  Practice i2me,  1  50 

Manual  of  Steam-boilers ,  Their  Designs,  Construction,  and  Operation .  8vo ,  5  00 

Weisbach's  Heat,  Steam,  and  Steam-engines.     (Du  Bois.) 8vo,  5  00 

Whitham's  Steam-engine  Dasign 8vo,  5  00 

Wilson's  Treatise  on  Steam-boilers.     (Flather.) '. i6mo,  2  50 

Wood's  Thermodynamics  Heat  Motors,  and  Refrigerating  Machines.  . .  .8vo,  4  00 


MECHANICS    AND  MACHINERY. 

Barr's  Kinematics  of  Machinery 8vo,   2  50 

Bovey's  Strength  of  Materials  and  Theory  of  Structures 8vo,    7  50 

Chase's  The  Art  of  Pattern-making i2mo,    2  50 

Church's  Mechanics  of  Engineering 8vo,    6  00 

13 


—     Church's  Notes  and  Examples  in  Mechanics 8vo 

Compton's  First  Lessons  in  Metal-working i2mo 

Compton  and  De  Groodt's  The  Speed  Lathe i2mo 

Cromwell's  Treatise  on  Toothed  Gearing i2mo 

Treatise  on  Belts  and  Pulleys i2mo 

Dana's  Text-book  of  Elementary  Mechanics  for  the  Use  of  Colleges  and 

Schools i2mo 

Dingey's  Machinery  Pattern  Making i2mo 

Dredge's  Record  of  the  Transportation  Exhibits  Building  of  the   World'; 

Columbian  Exposition  of  1893 4to   half  morocco 

Du  Bois's  Elementary  Principles  of  Mechanics : 

VoL     I. — Kinematics 8vo 

Vol.    II. — Statics   8vo 

Vol.  HI. — Kinetics 8vo 

Mechanics  of  Engineering.     Vol.   I Small   4to, 

VoL  IL Small  4to, 

Durley's  Kinematics  of  Machines  8vo 

Fitzgerald's  Boston  Machinist i6mo 

Flather's  Dynamometers,  and  the  Measurement  of  Power i2mo 

Rope  Driving i2mo 

Goss's  Locomotive  Sparks 8vo 

Hall's  Car  Lubrication i2mo 

Holly's  Art  of  Saw  Filing i8mo 

*  Johnson's  (W.  W.)  Theoretical  Mechanics i2mo 

Johnson's  (L.  J.)  Statics  by  Graphic  and  Algebraic  Methods 8vo 

Jones's  Machine  Design: 

Part   I. — Kinematics  of  Machinery 8vo 

Part  H. — Form,  Strength,  and  Proportions  of  Parts 8vo 

Kerr's  Power  and  Power  Transmission 8vo 

Lanza's  Applied  Mechanics 8vo 

Leonard  s  Machine  Shops,  Tools,  and  Methods.    (In  press.) 

MacCord's  Kinematics ;  or,  Practical  Mechanism 8vo 

Velocity  Diagrams   8vo 

Maurer's  Technical  Mechanics 8vo 

Merriman's  Text-book  on  the  Mechanics  of  Materials 8vo 

Elements  of  Mechanics i2mo 

*  Michie's  Elements  of  Analytical  Mechanics 8vo 

Reagan's  Locomotives:  Simple,  Compound,  and  Electric izmo 

Reid's  Course  in  Mechanical  Drawing , 8vo 

Text-book  of  Mechanical  Drawing  and  Elementary  Machine  Design . .  8vo 

Richards's  Compressed  Air i2mo 

Robinson's  Principles  of  Mechanism 8vo 

Ryan,  Norris,  and  Hoxie's  Electrical  Machinery.     Vol.  1 8vo 

Schwamb  and  Merrill's  Elements  of  Mechanism 8vo 

Sinclair's  Locomotive-engine  Running  and  Management i2mo 

Smith's  Press- working  of  Metals 8vo 

Materials  of  Machines i2mo 

Spangler,  Greene,  and  Marshall's  Elements  of  Steam-engineering 8vo 

Thurston's  Treatise  on  Friction  and  Lost  Work  in  Machinery  and  Mill 
Work 8vo 

Animal  as  a  Machine  and  Prime  Motor,  and  the  Laws  of  Energetics .  i2mo 

Warren's  Elements  of  Machine  Construction  and  Drawing 8vo 

Weisbach's  Kinematics  and  the  Power  of  Transmission.  (Herrmann- 
Klein.  ) 8vo 

Machinery  of  Transmission  and  Governors.     (Herrmann — Klein. ).8vo 

Wood's  Elements  of  Analytical  Mechanics 8vo 

Principles  of  Elementary  Mechanics i2mo 

Turbines 8vo 

The  World's  Columbian  Exposition  of  1893 4to 

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METALLURGY. 
Bgleston's  Metallurgy  of  Silver,  Gold,  and  Mercury: 

VoL    I.— Silver 8vo, 

VoL   II. — Gold  and  Mercury 8vo, 

**  Iles's  Lead  -smelting.     (Postage  9  cents  additional.) nmo, 

Keep's  Cast  Iron 8vo, 

Kuuhardt's  Practice  of  Ore  Dressing  in  Europe 8vo, 

Le  Chatelier's  High-temperature  Measurements.  (Boudouard — Burgess.) .  iimo,  3 

Metcalf's  SteeL     A  Manual  for  Steel-users i2mo, 

Smith's  Materials  of  Machines i2mo, 

Thurston's  Materials  of  Engineering.    In  Three  Parts 8vo, 

Part   II. — Iron  and  Steel 8vo, 

Part  III. — A  Treatise  on  Brasses,  Bronzes,  and  Other  Alloys  and  their 

Constituents 8vo, 

Ulke'a  Modern  Electrolytic  Copper  Refining 8vo, 

MINERALOGY. 

Barringer's  Description  of  Minerals  of  Commercial  Value.     Oblong,  morocco, 

Boyd's  Resources  of  Southwest  Virginia 8vo, 

Map  of  Southwest  Virginia Pocket-book  form, 

Brush's  Manual  of.  Determinative  Mineralogy.     (Penfield.) 8vo, 

Chester's  Catalogue  of  Minerals 8vo,  paper, 

Cloth, 

Dictionary  of  the  Names  of  Minerals 8vo, 

Dana's  System  of  Mineralogy Large  8vo,  half  leather, 

First  Appendix  to  Dana's  New  "System  of  Mineralogy.". ..  .Large  8vo, 

Text-book  of  Mineralogy 8vo, 

Minerals  and  How  to  Study  Them. . . ; i2mo. 

Catalogue  of  American  Localities  of  Minerals Large  8vo, 

Manual  of  Mineralogy  and  Petrography i2mo, 

Douglas's  Untechnical  Addresses  on  Technical  Subjects nmo, 

Eakle's  Mineral  Tables 8vo, 

Egleston's  Catalogue  of  Minerals  and  Synonyms 8vo, 

Hussak's  The  Determination  of  Rock-forming  Minerals.     (Smith.)  Small  8vo, 

Merrill's  Non-metallic  Minerals:  Their  Occurrence  and  Uses 8vo, 

*  Penfield's  Notes  on  Determinative  Mineralogy  and  Record  of  Mineral  Tests. 

8vo,  paper, 

Rosenbusch's   Microscopical  Physiography  of   the   Rock-making   Minerals. 

(Iddings.) 8vo, 

*  Tillman's  Text-book  of  Important  Minerals  and  Docks 8vo, 

Williams's  Manual  of  Lithology 8vo, 

MINING. 

Beard'B  Ventilation  of  Mines i2mo, 

Boyd's  Resources  of  Southwest  Virginia 8vo, 

Map  of  Southwest  Virginia Pocket-book  form, 

Douglas's  Untechnical  Addresses  on  Technical  Subjects i2mo, 

*  Drinker's  Tunneling,  Explosive  Compounds,  and  Rock  Drills. 

4*0,  half  morocco, 

Eissler's  Modern  High  Explosives 8vo, 

Fowler's  Sewage  Works  Analyses i2mo, 

Goodyear's  Coal-mines  of  the  Western  Coast  of  the  United  States. . i2mo, 

Ihlseng's  Manual  of  Mining 8vo, 

**  Iles's  Lead-smelting.     (Postage  oc.  additionaL) i2mo, 

Kunhardt's  Practice  of  Ore  Dressing  in  Europe 8vo, 

O'Driscoll's  Notes  on  the  Treatment  of  Gold  Ores : 8vo, 

*  Walke's  Lectures  on  Explosives 8vo, 

Wilson's  Cyanide  Processes iamo, 

Chlorination  Process lamo, 

15 


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Wilson's  Hydraulic  and  Placer  Mining i2mo, 

Treatise  on  Practical  and  Theoretical  Mine  Ventilation .  i2mo, 

SANITARY  SCIENCE. 

Folwell's  Sewerage.     (Designing,  Construction,  and  Maintenance.) 8vo, 

Water-supply  Engineering '. .  . 8vo, 

Fuertes's  Water  and  Public  Health nmo, 

Water-filtration  Works i2mo, 

Gerhard's  Guide  to  Sanitary  House-inspection i6mo, 

Goodrich's  Economical  Disposal  of  Town's  Refuse Demy  8vo, 

Hazen's  Filtration  of  Public  Water-supplies 8vo, 

Leach's  The  Inspection  and  Analysis  of  Food  with  Special  Reference  to  State 

Control. 8vo,    7  50 

Mason's  Water-supply.     (Considered    Principally    from    a    Sanitary    Stand- 
point.)    3d  Edition,  Rewritten 8vo, 

Examination  of  Water.     (Chemical  and  Bacteriological.) i2mo, 

Merriman's  Elements  of  Spnitary  Engineering 8vo, 

Ogden's  Sewer  Design i2mo, 

Prescott  and  Winslow's  Elements  of  Water  Bacteriology,  with  Special  Reference 
to  Sanitary  Water  Analysis i2mo, 

*  Price's  Handbook  on  Sanitation i2mo, 

Richards's  Cost  of  Food.     A  Study  in  Dietaries i2mo, 

Cost  of  Living  as  Modified  by  Sanitary  Science nmo, 

Richards    and  Woodman's  Air,  Water,  and  Food    from  a  Sanitary  Stand- 
point  8vo, 

*  Richards  and  Williams's  The  Dietary  Computer 8vo, 

Rideal's  Sewage  and  Bacterial  Purification  of  Sewage 8vo, 

Turneaure  and  Russell's  Public  Water-supplies 8vo, 

Von  Behring's  Suppression  of  Tuberculosis.     (Bolduan.).  .  ^  « nmo, 

Whipple's  Microscopy  of  Drinking-water 8vo, 

Woodhull's  Notes  and  Military  Hygiene i6mo, 

MISCELLANEOUS. 

De  Fursac's  Manual  of  Psychiatry.     (Rosanoff.) i2mo,    2  50 

Emmons's  Geological  Guide-book  of  the  Rocky  Mountain  Excursion  of  the 

International  Congress  of  Geologists Large  8vo, 

Ferrel's  Popular  Treatise  on  the  Winds 8vo, 

Haines's  American  Railway  Management i2mo, 

Mott's  Composition,  Digestibility,  and  Nutritive  Value  of  Food.  Mounted  chart. 

Fallacy  of  the  Present  Theory  of  Sound i6mo, 

Ricketts's  History  of  Rensselaer  Polytechnic  Institute,  1824- 1894.  Sirall  8vo, 

Rostoski's  Serum  Diagnosis.     (Bolduan.) i2mo, 

Rotherham's  Emphasized  New  Testament Large  8vo, 

Steel's  Treatise  on  the  Diseases  of  the  Dog 8vo, 

Totten's  Important  Question  in  Metrology 8vo, 

The  World's  Columbian  Exposition  of  1893 4to, 

Von  Behring's  Suppression  of  Tuberculosis.     (Bolduan.) i2mo, 

Worcester  and  Atkinson.     Small  Hospitals,  Establishment  and  Maintenance 
and  Suggestions  for  Hospital  Architecture,  with  Plans  for  a  Small 
Hospital i2mo,     1  25 

HEBREW  AND  CHALDEE  TEXT-BOOKS. 

Green's  Grammar  of  the  Hebrew  Language 8vo,    3  00 

Elementary  Hebrew  Grammar i2mo,    1  25 

Hebrew  Chrestomathy 8vo> 

Gesenius's  Hebrew  and  Chaldee  Lexicon  to  the  Old  Testament  Scriptures. 

(Tregelles.) Small  410,  half  morocco,     5 

Letteris's  Hebrew  Bible 8vo»    2  *5 

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COLUMBIA   UNIVERSITY   LIBRARIES 

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